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ANNUAL 

AND 

Analytical  Cyclop/edi 

OF 

Practical  Medicine 


BY 


CHARLES  E.  de  M.  SAJOUS  M.D. 

AND 

ONE  HUNDRED  ASSOCIATE  EDITORS 

ASSISTED  BY 

CORRESPONDING  EDITORS  COLLABORATORS 
AND  CORRESPONDENTS 


Illustrated  with  Cbrottio-EitbograpDs  Engravings  ana  maps 


volume:  iv 


Philadelphia  New  York  Chicago 
THE  F.  A.  DAVIS  COMPANY  PUBLISHERS 
1899 


COPYRIGHT,  1899, 

BY 

THE  F.  A.  DAVIS  COMPANY. 
[Registered  at  Stationers'  Hall,  London,  Eng.] 


Philadelphia,  Pa.,  U.  S.  A. 
The  Medical  Bulletin  Printing-House, 
1916  Cherry  Street. 


EDITORIAL  STAFF 


ASSOCIATE  EDITORS. 

{List  Revised  April  1,  1899.) 


J.  GEORGE  ADAMI,  M.D., 

MONTREAL,  P.  Q. 

LEWIS  H.  ADLER,  M.D., 

PHILADELPHIA. 

JAMES  M.  ANDERS,  M.D.,  LL.D., 

PHILADELPHIA. 

G.  APOSTOLI,  M.D., 

PARIS,  FRANCE. 

THOMAS  G.  ASHTON,  M.D., 

PHILADELPHIA. 

A.  D.  BLACKADER,  M.D., 

MONTREAL,  P.  Q. 

E.  D.  BONDURANT,  M.D., 

MOBILE,  ALA. 

DAVID  BOVAIRD,  M.D., 

NEW  YORK  CITY. 

WILLIAM  BROWNING,  M.D., 

BROOKLYN,  N.  Y. 

WILLIAM  T.  BULL,  M.D., 

NEW  YORK  CITY. 

C.  H.  BURNETT,  M.D., 

PHILADELPHIA. 

CHARLES  W.  BURR,  M.D., 

PHILADELPHIA. 

HENRY  T.  BYFORD,  M.D., 

CHICAGO,  ILL. 

J.  ABBOTT  CANTRELL,  M.D., 

PHILADELPHIA. 


WILLIAM  B.  COLEY,  M.D., 

NEW  YORK  CITY. 

P.  S.  CONNER,  M.D.,  LL.D, 

CINCINNATI,  OHIO. 

FLOYD  M.  CRANDALL,  M.D., 

NEW  YORK  CITY. 

ANDREW  F.  CURRIER,  M.D., 

NEW  YORK  CITY. 

ERNEST  W.  GUSHING,  M.D., 

BOSTON,  MASS. 

GWILYM  G.  DAVIS,  M.D., 

PHILADELPHIA. 

N.  S.  DAVIS,  M.D., 

CHICAGO,  ILL. 

F.  EKLUND,  M.D., 

STOCKHOLM,  SWEDEN. 

AUGUSTUS  A.  ESHNER,  M.D., 

PHILADELPHIA. 

J.  T.  ESKRIDGE,  M.D., 

DENVER,  COL. 

SIMON  FLEXNER,  M.D., 

BALTIMORE,  MD. 

LEONARD  FREEMAN,  M.D., 

DENVER,  COL. 

S.  G.  GANT,  M.D., 

KANSAS  CITY,  MO. 

J.  McFADDEN  GASTON,  Sr.,  M.D. 

ATLANTA,  GA. 

(iii) 


253405 


EDITORIAL  STAFF. 


J.  McFADDEN  GASTON,  Jr.,  M.D., 

ATLANTA,  GA. 

A.  GOUGUENHEIM,  M.D., 

PARIS,  FRANCE. 

J.  E.  GRAHAM,  M.D., 

TORONTO,  ONT. 

JULES  GRAND,  M.D., 

PARIS,  FRANCE. 

EGBERT  H.  GRANDIN,  M.D., 

NEW  YORK  CITY. 

LANDON  CARTER  GRAY,  M.D., 

NEW  YORK  CITY. 

J.  P.  CROZER  GRIFFITH,  M.D., 

PHILADELPHIA. 

C.  M.  HAY,  M.D., 

PHILADELPHIA. 

FREDERICK  P.  HENRY,  M.D., 

PHILADELPHIA. 

EDWARD  JACKSON,  M.D., 

DENVER,  COL. 

W.  W.  KEEN,  M.D., 

PHILADELPHIA. 

NORMAN  KERR,  M.D.,  F.L.S., 

LONDON,  ENGLAND. 

EDWARD  L.  KEYES,  Jr.,  M.D., 

NEW  YORK  CITY. 

H.  KRAUSE,  M.D., 

BERLIN,  GERMANY. 

E.  LANDOLT,  M.D., 

PARIS,  FRANCE. 

ERNEST  LAPLACE,  M.D.,  LL.D., 

PHILADELPHIA. 

R.  LEPINE,  M.D., 

LYONS,  FRANCE. 


F.  LEVISON,  M.D., 

COPENHAGEN,  DENMARK. 

A.  LUTAUD,  M.D., 

PARIS,  FRANCE. 

F.  W.  MARLOW,  M.D., 

SYRACUSE,  N.  Y. 

F.  MASSEI,  M.D., 

NAPLES,  ITALY. 

ALEXANDER  McPHEDRAN,  M.D., 

TORONTO,  ONT. 

E.  E.  MONTGOMERY,  M.D., 

PHILADELPHIA. 

JULES  MOREL,  M.D., 

GHENT,  BELGIUM. 

HOLGER  MYGIND,  M.D., 

COPENHAGEN,  DENMARK. 

W.  P.  NORTHRUP,  M.D., 

NEW  YORK  CITY. 

RUPERT  NORTON,  M.D., 

WASHINGTON,  D.  C. 

H.  OBERSTEINER,  M.D., 

VIENNA,  AUSTRIA. 

CHARLES  A.  OLIVER,  M.D., 

PHILADELPHIA. 

WILLIAM  OSLER,  M.D., 

BALTIMORE,  MD. 

F.  A.  PACKARD,  M.D., 

PHILADELPHIA. 

LEWIS  S.  PILCHER,  M.D., 

BROOKLYN,  N.  Y. 

WILLIAM  CAMPBELL  POSEY.  M.D., 

PHILADELPHIA. 

W.  B.  PRITCHARD.  M.D.. 

NEW  YORK  CITY. 


EDITORIAL  STAFF. 


v 


JAMES  J.  PUTNAM,  M.D., 

BOSTON,  MASS. 

B.  ALEXANDER  RANDALL,  M.D., 

PHILADELPHIA. 

ALFRED  RUBINO,  M.D., 

NAPLES,  ITALY. 

LEWIS  A.  SAYRE,  M.D., 

NEW  YORK  CITY. 

REGINALD  H.  SAYRE,  M.D., 

NEW  YORK  CITY. 

J.  SOLIS-COHEN,  M.D., 

PHILADELPHIA. 

SOLOMON  SOLIS-COHEN,  M.D., 

PHILADELPHIA. 

H.  W.  STELWAGON,  M.D., 

PHILADELPHIA. 

D.  D.  STEWART,  M.D., 

PHILADELPHIA. 

LEWIS  A.  STIMSON,  M.D., 

NEW  YORK  CITY. 

G.  ARCHIE  STOCKWELL,  M.D., 

NEW  YORK  CITY. 


A.  E.  TAYLOR,  M.D., 

PHILADELPHIA. 

LOUIS  McLANE  TIFFANY,  M.D., 

BALTIMORE,  MD. 

CHARLES  S.  TURNBULL,  M.D., 

PHILADELPHIA. 

HERMAN  F.  VICKERY,  M.D., 

BOSTON,  MASS. 

RIDGELY  B.  WARFIELD,  M.D., 

BALTIMORE,  MD. 

F.  E.  WAXHAM,  M.D., 

CHICAGO,  ILL. 

J.  WILLIAM  WHITE,  M.D., 

PHILADELPHIA. 

W.  NORTON  WHITNEY,  M.D., 

TOKIO,  JAPAN. 

JAMES  C.  WILSON,  M.D., 

PHILADELPHIA. 

C.  SUMNER  WITHERSTINE,  M.D., 

PHILADELPHIA. 

WALTER  WYMAN,  M.D., 

WASHINGTON,  D.  C. 


PREFACE  TO  THE  FOURTH  VOLUME. 


The  manner  in  which  the  members  of  the  medical  profession  have  received 
the  previous  volumes  of  the  Annual  and  Analytical  Cyclopedia  of  Pkactical 
Medicine  has  been  so  encouraging  that  it  is  with  renewed  pleasure  that  the  editor 
places  the  fourth  issue  before  his  readers.  The  marked  success  implied  has  not 
only  been  due  to  the  novel  plan  of  the  work, — a  general  article  upon  each  disease, 
sustained  by  the  salient  points  of  the  literature  of  the  last  ten  years, — but  also 
to  the  excellence  of  the  general  articles  (presented  in  large  type)  written  by  the 
members  of  the  associate  staff.  To  all  of  these  gentlemen  the  editor  wishes,  there- 
fore, to  renew  his  expressions  of  gratitude. 

It  is  with  deep  sorrow  that  the  editor  must  record  the  death  of  his  friend, 
Professor  George  H.  Rohe,  of  Baltimore,  who  had  been  connected  with  the  Annual 
since  1891.  To  enumerate  his  qualities  would  imply  that  he  had  faults.  Those 
who  knew  him  well  could  but  conclude  that  if  we  were  all  of  his  kind  the  world 
would  be  one  where  generosity  and  affection  would  reign  supreme.  One  of  Dr. 
Rohe's  last  contributions  appears  in  this  volume:  a  review  on  the  subject  of 
"Insanity,"  calculated  to  clearly  define  the  practical  aspect  of  the  various  mental 
disorders,  not  only  for  clinical  purposes,  but  for  the  court-room.  How  thoroughly 
our  departed  friend  has  accomplished  his  task  the  reader  will  appreciate.  It  is 
in  keeping  with  the  sincerity  of  purpose  that  characterized  him. 

This  volume  contains,  besides  the  article  on  "Insanity,"  a  timely  paper  on 
the  "Diarrhceal  Diseases  of  Infants,"  by  Professor  Blackader,  of  Montreal.  During 
the  coming  summer  its  great  scientific  value  will  doubtless  be  recognized.  An 
elaborate  paper  on  "Malarial  Fevers,"  by  Professor  James  C.  Wilson  and  Dr.  Thomas 
G.  Ashton,  will  also,  it  is  hoped,  receive  the  great  appreciation  to  which  it  is 
entitled.  The  article  on  "Locomotor  Ataxia,"  by  Dr.  W.  B.  Pritchard,  of  New 
York;  that  on  "Intubation,"  by  Professor  F.  E.  Waxham,  of  Chicago;  and  that 
on  "Diseases  of  the  Liver,"  by  Professor  Alexander  McPhedran,  of  Toronto;  that 
on  "Meningitis,"  by  Dr.  Charles  M.  Hay,  of  Philadelphia,  are  also  entitled  to 
special  notice  as  models  of  their  kind.  The  editor  must  express  his  regret  that 
through  unavoidable  circumstances  he  was  obliged  to  write  the  article  on  "Leprosy" 
himself,  and  at  the  last  moment.  Still,  the  fact  that  he  has  had  the  opportunity 
of  seeing  quite  a  number  of  cases  during  his  travels  and  the  important  role  played 
by  the  upper  respiratory  tract  in  the  etiology  of  the  disease  lead  him  to  hope  that 
he  may  have  treated  the  subject  with  a  certain  degree  of  competence. 

The  Editor. 

2043  Walnut  Street, 
Philadelphia,  April  1,  1899. 


(vii) 


Sajous's  Annual 

and 

Analytical  Cyclopedia  of  Practical 

Medicine. 


i 


INFANTS,  DIARRHEAL  DISEASES 

OF. — Gr.,  from  &d,  through,  and  pelv, 
to  flow. 

Definition. — Diarrhoea  in  itself  can  be 
regarded  as  a  symptom  only:  a  symptom 
indicative  of  increased  motor  activity 
and  of  increased,  and  perhaps  perverted, 
secretory  activity  in  the  intestinal  canal. 

Disturbance  of  the  intestinal  activity 
is  sometimes  due  merely  to  the  pres- 
ence in  the  alimentary  tract  of  irritat- 
ing and  noxious  material  and  the  in- 
creased secretion  and  peristalsis  is  to  be 
regarded  as  an  effort  of  nature  to  get  rid 
of  offending  material;  an  effort  which, 
if  effective,  and  not  unduly  severe  or  pro- 
longed, must  be  considered  as  entirely 
salutary  in  its  character.  More  fre- 
quently, diarrhoea,  especially  in  infants, 
must  be  regarded  as  one  symptom  only 
of  an  intoxication  of  the  system  by  toxins 
the  product  of  pathogenic  micro-organ- 
isms present  in  the  alimentary  canal:  a 
symptom  important  in  itself,  but  not  to 
be  considered  apart  from  other  symp- 
toms of  systemic  intoxication, — such  as 
fever,  quickened  and  enfeebled  cardiac 
action,  and  nervous  prostration. 

In  many  of  these  cases  inflammatory 
changes  more  or  less  extensive  in  char- 
acter are  set  up  in  the  walls  of  the  intes- 
tines: such  changes  may  be  due  to  some 


extent  to  the  abnormal  and  irritating 
character  of  the  intestinal  contents,  but, 
to  a  much  greater  degree,  they  result 
from  the  specific  action  of  the  bacterial 
toxins.  In  some  instances  the  bacteria 
themselves  appear  to  penetrate  the  tis- 
sues of  the  intestinal  wall;  destructive 
changes  are  thus  induced  which  not  only 
aggravate  the  general  symptoms,  but, 
should  the  case  survive,  indefinitely  re- 
tard recovery. 

Owing  to  the  abnormal  activity  of 
peristalsis  by  which  food  is  unduly  hur- 
ried through  the  alimentary  tract  and  to 
an  alteration  in  the  various  digestive 
fluids,  either  quantitative  or  qualitative, 
the  process  of  digestion  is  performed 
more  or  less  imperfectly;  owing,  also,  to 
inflammatory  changes  in  the  walls  of  the 
intestine,  absorption  is  hindered  and 
general  nutrition  becomes  rapidly  im- 
paired. In  some  cases,  where  the  diar- 
rhoea is  of  a  grave  character,  or  persists 
throughout  a  long  period  of  time,  the 
emaciation  becomes  extreme. 

Diarrhoea  is  thus  of  much  importance 
as  a  clinical  symptom;  for  this  reason  it 
has  long  been  customary  to  group  to- 
gether under  the  name  used  generically 
all  those  disorders  which  have,  as  their 
prominent  and  most  important  symptom, 
an  increased  motor  and  secretory  activity 


4—1 


2 


INFANTS,  DIAREHCEAL 


DISEASES.  ETIOLOGY. 


of  the  intestinal  tract  from  whatever 
cause  arising.  This  use  of  the  name  lacks 
scientific  precision;  nevertheless,  while 
our  knowledge  of  many  of  the  conditions 
met  with  in  these  disorders  is  still  inexact 
and  uncertain,  it  does  not  seem  wise  to 
attempt  more  precise  definition. 

Infants  under  the  age  of  thirty  months 
are  peculiarly  prone  to  diarrhceal  dis- 
orders. In  such  infants  disorders  of  the 
intestinal  tract  present  an  etiology  and 
pathology  peculiar  to  themselves,  and  in 
them,  to  a  much  greater  extent  than  in 
older  children  or  in  adults,  has  the  dis- 
ease a  tendency  to  run  a  severe  course, 
and  in  a  large  proportion  of  cases  to  ter- 
minate fatally.  For  this  reason  the  sub- 
ject of  infantile  diarrhoea  claims  separate 
consideration. 

Etiology. — If  we  inquire  into  the 
causes  which  induce  this  liability  to  diar- 
rhceal disease  on  the  part  of  infants,  a 
few  facts  stand  out  prominently. 

The  Season. — The  diarrhoeas  of  in- 
fancy take  a  comparatively  unimportant 
rank  among  infantile  diseases  during  the 
cooler  months  of  the  year,  but  with  the 
onset  of  warm  weather  they  suddenly  ac- 
quire importance,  owing  to  their  general 
severity,  to  their  large  mortality,  and  to 
the  frequency  with  which  they  are  en- 
countered. This  is  evidenced  by  the 
statistics  of  all  large  cities  in  the  tem- 
perate zones.  Whenever  the  minimum 
temperature  of  the  atmosphere  for  the 
twenty-four  hours  reaches  the  neighbor- 
hood of  60°  F.,  infantile  diarrhoeas  as- 
sume the  character  of  a  wide-spread  epi- 
demic. An  attempt  has  been  recently 
made  by  some  English  physicians  to  con- 
nect the  epidemic  character  of  the  disease 
with  the  temperature  of  the  soil.  Dr. 
Ballard,  after  careful  investigation,  states 
that  the  mortality  from  this  class  of  dis- 
orders does  not  begin  until  the  ther- 
mometer registers  a  temperature  of  56° 


F.  four  feet  below  the  surface.  That 
there  is  any  relation  of  cause  and  effect 
between  the  two  facts,  however,  has  in 
no  way  been  proved. 

Age. — An  investigation  of  the  age  of 
children  thus  attacked  reveals  the  fact 
that  the  great  majority  are  under  2  years. 
Holt  has  given  us  the  statistics  of  3000 
cases  of  diarrhoea  treated  in  family  and 
dispensary  practice,  classified  according 
to  age. 

He  finds  that,  of  the  total  number,  in- 
fants under  6  months  form  14  per  cent.; 
infants  from  6  to  12  months,  29  per  cent.; 
infants  from  12  to  18  months,  24  per 
cent.;  infants  from  18  to  24  months,  17 
per  cent.;  and  children  over  2  years,  16 
per  cent.  In  France,  Lesage  places  the 
age  of  special  liability  as  under  18 
months  and  regards  the  first  3  months, 
and  also  the  period  between  the  eighth 
and  ninth  months,  when  weaning  is  gen- 
erally commenced,  as  specially  danger- 
ous. 

The  age  at  which  diarrhceal  diseases 
are  most  prevalent  has  been  investigated 
by  the  writer.  In  3000  cases  occurring 
in  New  York  City  the  ages  are  shown  in 
the  following  table:  — 


Per- 

Cases. 

centage 

First  six  months.  .  .  . 

.  .  413 

13.7 

Second  six  months.  . 

.  .  873 

20.1 

Third  six  months.  .  , 

722 

24.1 

Fourth  six  months.  . 

.  .  514 

17.2 

Over  two  years  

.  .  478 

15.9 

Under  two  years.  .  . . 

2522 

84.1 

Between  six  and 

eighteen  months 

1505 

53.2 

Crandall  (Archives  of  Ped.,  Nov 

,  '90). 

Literature  of  W-W-'dS. 

A  recent  report  of  the  Health  Board 
of  New  York  City  shows  that  there  was 
for  one  year  2789  deaths  from  diarrhoeal 
affections,  and  of  these  deaths  92  per 
cent,  occurred  in  children  less  than  2 
years  of  age.  Gilbert  (Amer.  Pract.  and 
News,  Oct.  16,  '07). 

Diarrhoea  appears  to  be  most  frequent 


INFANTS,  DIARRHCEAL  DISEASES.  ETIOLOGY. 


3 


among  children  under  one  year  of  age.  j 
In  England  and  Wales  in  1894  the  j 
deaths  of  children  from  diarrhoea  under 
five  years  old  amounted  to  9005.  Of 
these,  7360  were  infants  under  one  year; 
1332  occurred  during  the  second  year; 
while,  in  the  third,  fourth,  and  fifth 
years  combined,  there  were  only  313. 
Again,  in  London,  72  per  cent,  of  all 
fatal  diarrhoeas  occur  in  the  first  year  of 
life.  Langford  Symes  (Dublin  Jour. 
Med.  Sci.,  May,  '97). 

Mode  of  Feeding. — It  is  the  experi- 
ence of  every  physician  who  has  kept  a 
record  of  his  cases  that  fatal,  or  even 
severe,  cases  of  diarrhoea  among  infants  I 
fed  entirely  at  the  breast  are  extremely 
rare.  Holt  emphasizes  this,  when  he  says 
that,  of  1943  fatal  cases  of  which  he  has 
collected  the  records,  only  3  per  cent, 
were  breast-fed  exclusively.  He  refers 
the  partial  immunity  which,  according  j 
to  his  statistics,  infants  under  six  months 
enjoy  to  the  fact  that  the  great  majority 
of  such  are  breast-fed,  and  in  this  way 
obtain  a  sterile  and  digestible  food.  With 
the  commencement  of  artificial  feeding, 
gastro-intestinal  disorders  at  once  ac- 
quire prominence.  Too  often  the  food 
substituted  for  breast-milk  is  more  or 
less  difficult  of  digestion,  defective  in 
composition,  and  liable  to  be  supplied  to 
the  infant  too  frequently  or  in  too  large 
amounts,  in  this  way  setting  up  indi- 
gestion: the  most  important  predispos- 
ing cause  of  infantile  diarrhoea.  But,  as 
we  all  know,  the  materials  supplied  as 
food  to  the  infant  may  be  of  the  most 
faulty  character,  inducing  indigestion, 
colic,  and  malnutrition  in  one  or  other  of 
its  various  forms,  and  yet  during  the  cool 
season  we  meet  with  either  no  diarrhoea 
or  diarrhoea  of  a  temporary  and  easily 
controlled  form. 

Healthy  infants  have  a  normal  tend- 
ency to  loose,  liquid,  and  semiliquid 
evacuations  from  the  bowels:  (1)  partly 
from  the  condition  of  the  intestinal 
tract;    (2)   partly  from  the  nature  of 


normal  food,  i.e.,  breast-milk.  Peristaltic 
movements  in  the  healthy  child  are  very 
active.  Young  blood-  and  lymphatic 
vessels  are  very  permeable  and  the  trans- 
formation of  the  surface-cells  active  and 
rapid.  The  peripheral  nerves  are  very 
superficial,  more  so  than  in  adults, 
whose  mucous  membrane  and  submucous 
tissue  have  undergone  thickening  by 
both  normal  development  and  morbid 
processes.  Besides,  the  action  of  the 
sphincter  ani  is  not  very  powerful. 
Faeces  are  not  retained  in  the  colon  and 
rectum,  and  little  time  is  afforded  for 
the  reabsorption  of  the  liquid  or  dis- 
solved fsecal  contents.  Frequency  of 
acids  (sometimes  normal)  in  the  small 
intestine  gives  rise  to  formation  of  al- 
kaline salts  with  purgative  properties- 
Free  acids  when  found  in  the  intestine 
show  that  ( 1 )  the  quantity  of  food  is  too 
large;  (2)  the  quantity  of  digestive 
fluid  is  too  small,  causing  fermentation 
instead  of  normal  digestion.  Louis 
Fischer  (The  Post-graduate,  Sept.,  '92). 

Of  58  deaths  among  children  entirely 
raised  by  mothers'  milk  none  had  un- 
cooked fruit  given  them.  In  6  of  these 
cases  the  mother  herself  had  eaten  un- 
cooked fruit.  In  2  instances  1  of  the 
mothers  had  eaten  boiled  apples  and  the 
other  cauliflower;  so  that  there  were  8 
out  of  58  cases  in  which  fruit  might  be 
regarded  as  connected  with  the  child's 
diarrhoea.  Of  135  children  under  3  years 
of  age,  not  at  the  breast,  whose  deaths 
were  inquired  into,  2  ate  fruit;  the  re- 
maining 133  are  distinctly  stated  not  to 
have  had  any. 

Of  the  605  fatal  cases  of  diarrhoea  in 
Leeds  in  1893,  66  per  cent,  occurred  in 
houses  either  without  drains  or  with 
drains  not  properly  severed  from  the 
sewer,  and  one-fifth  of  the  remainder 
(making  73  per  cent.)  had  other  sanitary 
defects.  It  is  to  the  feeding-bottle  and 
to  the  infection  of  its  contents  rather 
than  to  fruit  that  attention  must  be 
most  especially  directed  in  the  preven- 
tion of  autumnal  diarrhoea.  J.  S.  Cam- 
eron (Lancet,  June  30,  '94). 

Literature  of  '96-'97-'98. 

Infective  diarrhoea  sometimes  rages  as 
an  epidemic.    It  practically  never  occurs 


4 


INFANTS,  DIARRHEAL  DISEASES.    ETIOLOGY.  PATHOLOGY. 


in  breast-fed  children  (at  least  in  only 
3  per  cent).  Neglect  or  deficiency  of 
ventilation  seems  to  be  a  very  important 
cause,  and  the  bacteria  in  question  ap- 
pear to  inhabit  the  superficial  layers  of 
the  earth,  becoming  wide-spread  when 
the  temperature  reaches  58°  F.  Lang- 
ford  Symes  (Dublin  Jour.  Med.  Science, 
June,  '97). 

Defective  water-supply  appears  to 
affect  the  children  over  5  years  of  age, 
but  infants  are  swept  away  in  hundreds 
by  milk  which  is  infected  or  contami- 
nated. The  greater  number  of  fatal  diar- 
rhoeas are  doubtless  due  to  artificial 
feeding.  All  organisms  grow  and  flourish 
in  milk.  Symes  (Brit.  Med.  Jour.,  May 
8,  '97). 

For  the  exciting  cause,  therefore,  of 
the  severe  diarrhoeas  of  infancy  we  must 
seek  further;  such  a  cause,  it  is  now  al- 
most universally  conceded,  exists  in  the 
growth  in  the  intestinal  tract  of  toxin- 
producing  bacteria.  Such  bacteria,  prob- 
ably, in  the  majority  of  cases  are  intro- 
duced with  the  food.  During  the  colder 
seasons  of  the  year  these  bacteria,  while 
present  more  or  less  everywhere,  remain 
quiescent,  but,  with  the  onset  of  warmer 
-weather  they  multiply  in  any  suitable 
medium  with  a  rapidity  almost  in- 
credible. No  article  of  infant-diet  ap- 
pears to  be  so  readily  contaminated  as 
cows'  milk;  not  only  is  it  liable  to  be  in- 
fected from  many  sources,  but  at  the 
same  time  it  affords  an  excellent  culture- 
medium  for  almost  all  forms  of  bacteria. 
Hence  to  it,  more  than  to  any  other 
article  of  diet,  are  disastrous  effects  at- 
tributed. Moreover,  it  was  formerly  sup- 
posed that  the  acidity  of  the  gastric  juice, 
in  the  infant  as  in  the  adult,  stood  guard 
with  a  certain  amount  of  germicidal 
power  at  the  portal  of  the  intestinal 
tract,  where,  even  under  normal  condi- 
tions, there  appears  to  be  little  hindrance 
to  bacterial  growth.  Traube  and  Esche- 
rich,  however,  have  shown  that  in  young 
in  fan  is  the  stomach  has  but  slight  power 


of  either  digestion  or  absorption,  and  is 
rather  a  receptacle  into  which  the  milk 
is  received  for  coagulation,  and  from 
which  it  quickly  passes  into  the  small  in- 
testine, where  it  meets  the  proteolytic 
ferment  of  the  pancreas,  relatively  well 
developed  even  at  an  early  age.  Owing 
to  this  there  is  practically  no  hindrance 
to  the  development  of  bacteria  in  the 
alimentary  tract  of  the  infant,  save  the 
rapidity  and  completeness  with  which 
the  digestive  process  is  performed.  Indi- 
gestion, therefore,  by  permitting  fer- 
|  mental  changes,  furnishes  the  conditions 
under  which  any  pathogenic  bacteria, 
either  just  introduced  by  means  of  con- 
taminated food  or  present  in  the  canal 
but  previously  hindered  in  development, 
may  flourish  and  evolve  their  poisonous 
toxins. 

As  additional  predisposing  causes,  we 
may  add  that  all  conditions  which  lower 
the  vitality  of  the  infant  tend  to  impair 
digestion,  and,  to  this  extent,  favor  the 
development  of  diarrhoea.  Defective  hy- 
gienic conditions,  previous  acute  disease, 
and  malnutrition  in  all  its  forms,  espe- 
cially rachitis,  syphilis,  and  tuberculosis, 
appear  to  act  in  this  way.  Summer-heat 
directly  prostrating  the  nervous  system, 
overexcitement,  and  occasionally  the 
nerve-irritation  accompanying  dentition, 
have  all  an  influence  more  or  less  dis- 
turbing on  digestion,  and  may,  therefore, 
be  regarded  as  predisposing  causes  of 
diarrhoea. 

General  Pathology.  —  The  normal 
I  faeces  of  a  healthy  infant  fed  at  the  breast 
should  be  of  a  smooth  and  homogeneous 
|  nature,  of  semisolid  consistence,  of  a 
dull-lemon  color,  and  of  a  not  unpleasant 
odor.  They  should  have  an  acid  reaction, 
due  to  the  presence  of  fatty  acids  and  of 
a  small  amount  of  lactic  acid.  Fat, 
chiefly  in  the  form  of  neutral  fats,  fatty 
acids,  and  soaps,  is  almost  always  present, 


INFANTS,  DIARRHCEAL 


DISEASES.  PATHOLOGY. 


5 


sometimes  in  considerable  amount. 
Sugar  is  never  present.  Proteids,  in 
breast-fed  children,  are  present  in  small 
amount;  but,  in  infants  fed  on  cows' 
milk,  casein  is  met  with  in  considerable 
quantity,  rendering  such  motions  firmer 
in  consistence,  paler  in  color,  larger  in 
amount,  and  with  a  distinctly  more  un- 
pleasant odor.  In  breast-fed  infants, 
under  normal  conditions,  the  bile- 
elements  for  the  most  part  remain  un- 
altered, but,  as  the  diet  becomes  changed, 
the  biliary  pigments  become  decomposed, 
and,  with  the  mixed  diet  of  the  second 
and  third  years  of  life,  the  fasces  resemble 
those  of  the  adult,  excepting  that  they 
are  less  firm  and  more  or  less  acid  in  re- 
action. Mucus  is  present  to  a  consider- 
able extent;  also  epithelial  cells,  chiefly 
of  the  columnar  variety. 

Under  the  influence  of  diarrhceal  con- 
ditions, the  faecal  discharges  become 
much  altered.  At  the  onset,  and  persist- 
ing so  long  as  due  attention  is  not  given 
to  the  feeding,  undigested  food  is  always 
more  or  less  present.  Masses  of  casein 
are  frequently  seen,  and  may  be  easily  I 
recognized;  fat  may  be  present  in  small 
yellowish-white  masses,  somewhat  re- 
sembling the  former  in  appearance,  but 
distinguished  by  solubility  in  ether.  Un- 
changed starch  may  be  recognized  by  the 
iodine  test.  The  number  of  the  dis- 
charges during  the  twenty-four  hours 
may  vary  from  four  or  five  to  twenty  or 
more.  Their  odor  is  probably  dependent 
upon  the  character  of  the  fermentation 
present.  When  sour,  an  acid  fermenta- 
tion, and,  when  very  offensive,  albumi- 
nous decomposition  is  supposed  to  exist. 
The  reaction  is  almost  invariably  acid; 
only  when  the  discharges  are  more  of  an 
exudative  than  of  a  faecal  character  does 
the  reaction  become  distinctly  alkaline. 
The  color  is  very  variable.  The  most  j 
noticeable  change  is  to  a  varying  shade  of  I 


green,  due,  according  to  Wegscheider,  to 
the  conversion  of  bilirubin  into  biliver- 
din.  Lesage,  however,  states  that  this 
green  color  is  not  always  due  to  biliver- 
din,  but  is  sometimes  due  to  a  chro- 
mogenic  microbe  of  which  the  pigment 
stains  the  stools;  other  observers,  how- 
ever, have  not  verified  this  statement. 
The  amount  of  mucus  is  almost  always 
increased,  in  some  instances  very  largely 
so;  when  it  is  seen  in  quantity,  it  gener- 
ally indicates  a  local  congestion  of  the 
lower  portion  of  the  colon.  Blood  is  oc- 
|  casionally  seen,  due  sometimes  to  ulcera- 
tion, but  more  frequently  to  local  con- 
gestion and  straining. 

At  birth,  the  intestinal  tract  of  the  in- 
fant is  free  from  bacteria.  This  condi- 
tion, however,  is  quickly  changed,  and 
even  in  otherwise  healthy  infants,  many 
forms  may  be  found  in  the  faecal  dis- 
charges a  few  days  after  birth.  Under 
normal  breast  -  feeding,  however,  and 
with  good  digestion,  two  varieties  of 
bacilli  are  constantly  found,  and,  for  this 
reason,  have  been  termed  the  constant, 
or  obligatory,  forms  of  healthy-milk 
faeces;  they  are  the  bacilli  coli  communes 
and  the  bacilli  lactis  aerogenes.  The 
latter  abound  in  great  numbers  in  the 
upper  part  of  the  small  intestine,  where 
they  appear  to  thrive  in  the  yet-imper- 
fectly-digested milk-curds.  In  the  lower 
part  of  the  small  intestine  and  upper 
part  of  the  colon  they  are  met  with  in 
gradually  diminishing  numbers,  while 
the  bacilli  coli  communes,  which  in  the 
small  intestine  are  found  only  in  com- 
paratively small  numbers,  now  multiply 
rapidly;  so  that  in  the  lower  part  of  the 
colon  and  in  the  faeces  they  greatly  pre- 
dominate over  the  preceding  form  and 
over  other  less  constant  varieties. 

When  breast-feeding  is  replaced  by 
a  more  mixed  diet,  other  forms  of  bac- 
teria are  found  in  variable  numbers  and 


6 


INFANTS,  DIARRHCEAL  DISEASES.  PATHOLOGY. 


in  an  inconstant  way;  among  those  fre- 
quently met  with  are  the  streptococcus 
coli  gracilis,  various  forms  of  micrococci, 
various  liquefying  bacilli,  and  the  bacil- 
lus subtilis. 

In  the  discharges  of  diarrhoea  some 
new  forms  make  their  appearance  in 
great  abundance,  but,  with  the  exception 
of  the  two  before  mentioned  as  always 
present,  no  one  variety  is  so  constantly 
met  with  as  to  permit  it  to  be  regarded  as 
a  specific  cause.  From  several  of  these 
inconstant  forms,  however,  Vaughan  has 
isolated  proteid  substances,  which  when 
injected  in  very  minute  quantities  under 
the  skin  of  animals  produce  poisonous 
symptoms,  such  as  vomiting  and  purg- 
ing, with  elevation  of  temperature,  and 
in  larger  doses  collapse  and  death.  The 
question  as  to  whether  either  of  the  ob- 
ligatory forms  under  the  abnormal  con- 
ditions met  with  in  diarrhoea  develop 
pathogenic  properties,  though  much  dis- 
cussed, can  scarcely  be  said  to  be  defi- 
nitely settled.  Of  one,  the  bacillus  coli 
communis,  recent  studies  indicate  that  it 
may  undoubtedly  at  times  develop  viru- 
lent pathogenic  properties. 

Booker,  to  whom  the  medical  world  is 
indebted  for  a  careful  investigation  of 
this  subject,  states  that  in  infantile  diar- 
rhoea the  conditions  for  the  development 
of  bacteria  in  the  intestinal  canal  appear 
to  differ  from  those  obtaining  in  the 
healthy  intestine  of  milk-fed  infants. 
The  bacterial  forms  present  a  greater 
variety;  forms  met  with  only  occasion- 
ally and  in  small  numbers  in  the  healthy 
intestine  are  now  much  more  pro- 
nounced, and  frequently  appear  in  im- 
mense numbers;  while  the  bacillus  coli 
communis  and  the  bacillus  lactis  aerog- 
enes  become  more  uniformly  dis- 
tributed through  the  intestine.  No 
single  species  of  micro-organism  is  met 
with  sufficiently  frequently  to  be  re- 


I  garded  in  itself  as  the  specific  exciter  of 

[  diarrhoea;  but  among  the  many  forms 
encountered  several  varieties  of  strepto- 
cocci and  the  proteus  vulgaris  appear  to 
be  of  special  importance.    The  strepto- 

I  cocci  are  met  with  frequently;  occasion- 
ally seen  in  the  stomach  and  upper  part 
of  the  small  intestine,  they  become  much 
more  abundant  in  the  lower  ileum  and 
colon,  especially  in  those  cases  where  ul- 
ceration of  the  mucosa  is  going  on.  So 
constantly  and  in  such  large  numbers  are 
they  found  in  these  cases  that  it  is  reason- 
able to  suppose  that  they  play  an  active 
and  important  role  in  the  ulcerative 
process.  Of  the  proteus  vulgaris,  Booker 
says  that  it  is  found  in  more  than  half 
of  the  severer  cases  of  diarrhoea;  in  the 

|  milder  forms  it  is  seldom  met  with. 
Cases  in  which  this  bacillus  abounds 
present  a  different  type  of  symptoms  to 
those  in  which  streptococci  prevail;  the 
patients  more  frequently  show  toxic  phe- 
nomena and  have  watery  or  pasty  stools 
with  a  putrid  odor,  but  without  evidence 
of  serious  inflammatory  trouble  in  the 
intestine. 

Among  other  forms  of  bacteria  possess- 
ing pathogenic  properties  encountered 
we  may  mention  the  staphylococcus 
pyogenes,  the  bacillus  pyocyaneus,  the 
bacillus  mesentericus,  and  the  bacillus 
enteritidis  (Gartner).  Such  forms  prob- 
ably more  or  less  modify  the  symptoms  in 
special  cases. 

Although  at  birth  the  contents  of  the 
digestive  tract  are  sterile,  bacterial  in- 
fection is  brought  about  within  the  first 
twelve  hours  of  life  through  the  medium 
of  the  atmospheric  air  which  the  infant 
swallows  in  large  quantities.  The  vari- 
ous micro-organisms  thus  introduced 
into  the  system  thrive  and  multiply  in 
the  mucus  and  undigested  food  which 
soon  fill  the  intestine,  and  are  constantly 
reinforced  in  numbers  and  diversified  in 
species  by  the  ingestion  of  contaminated 
milk  or  the  swallowed  secretions  of  the 


INFANTS,  DIARRHEAL  DISEASES.  PATHOLOGY. 


mouth.  The  danger  which  arises  from 
these  natural  sources  of  infection  is 
greatly  increased  by  the  fact  that  during 
infant-life  the  gastric  juice  is  incapable  of 
exerting  any  decided  control  over  mi- 
crobic  growth,  owing  to  its  comparative 
deficiency  in  free  hydrochloric  acid.  The 
entrance  of  undigested  and  fermenting 
material  into  the  intestine  induces 
violent  peristalsis,  with  the  result  that 
the  infant  suffers  from  colic  and  diar- 
rhoea until  the  bowel  has  succeeded  in 
ridding  itself  of  its  irritating  contents. 
If  proper  means  are  taken  to  assist 
Nature  and  to  prevent  a  recurrence  of 
the  disorder,  the  stools  soon  resume  their 
normal  appearance  and  perfect  recovery 
ensues.  But  if  these  evidences  of  di- 
gestive derangement  are  overlooked, 
gastro-intestinal  catarrh  supervenes. 
This  inflammatory  condition  probably 
arises  from  direct  irritation  of  the  mu- 
cous membrane  of  the  digestive  tract  by 
acid  products  of  fermentation,  and  since 
it  is  always  accompanied  by  a  diminu- 
tion in  the  secretion  of  hydrochloric 
acid,  gastric  digestion  becomes  greatly 
enfeebled,  and  the  various  bacteria  are 
afforded  an  unlimited  scope  of  action. 
Within  a  short  period  of  time  the  intes- 
i  tine  becomes  affected  in  a  similar  man- 
ner, and  the  child  begins  to  lose  flesh  and 
strength  and  to  present  all  the  symp- 
toms characteristic  of  chronic  intestinal 
catarrh.  The  third  and  last  stage  of  the 
disease  is  marked  by  a  more  or  less  ex- 
tensive cirrhosis  of  the  mucous  mem- 
brane of  the  digestive  tract,  often  asso- 
ciated with  the  follicular  ulceration  of 
the  colon.  The  diarrhoea  continues  and 
the  stools  are  largely  mixed  with  mucus 
or  streaked  with  blood;  the  marasmus 
increases,  and  death  finally  ensues  either 
from  exhaustion  or  from  some  nervous 
phenomena  due  to  the  absorption  of  tox- 
ins from  the  alimentary  tract.  W. 
Soltau  Fenwick  (Brit.  Med.  Jour.,  Dec. 
21,  '95). 

[Fifteen  varieties  of  bacteria  have  been 
isolated  from  the  stools  of  children  suf- 
fering from  summer  diarrhoea,  in  addi- 
tion to  the  B.  coli  commune  and  B.  lactis 
aerogenes  of  Escherich,  and  the  forms  are 
not  yet  exhausted.  The  great  majority 
of  the  bacteria  belonged  to  the  group 


classed  as  saprophytic.  No  constant 
form  was  found,  and  no  one  form  pre- 
dominated in  a  large  proportion  of  the 
cases.  Baginsky,  Cor.  Ed.,  Annual,  '91.] 
The  development  of  intestinal  bacteria 
depends  quite  as  much,  if  not  more,  upon 
the  character  of  the  bowel  and  its  con- 
tents than  upon  the  accidental  presence 
of  this  or  that  bacterium.  Carter 
(Provincial  Med.  Jour.,  May  1,  '93). 

Literature  of  '96-'97-'98. 

Study  of  the  stools  clearly  showing 
that  no  single  species  of  micro-organism 
is  responsible  for  the  disease,  and  also, 
in  a  general  way,  that  the  character 
of  the  passages  and  the  nature  of  the 
systemic  disturbance  conform  to  the 
character  of  the  intestinal  infection. 

In  a  considerable  number  of  these  cases 
the  obligatory  milk-fseces  bacteria  were 
found  to  be  the  chief  bacterial  ingredient 
of  the  stools.  These  were  for  the  most 
part  mild  cases,  of  short  duration,  and 
usually  without  apparent  toxic  symp- 
toms. The  stools  were  sometimes  very 
frequent,  were  usually  acid  in  reaction, 
and  lacked  uniformity  of  consistence, 
having  been  often  lumpy.  They  con- 
tained no  leucocytes.  Twenty-four  cases 
of  this  type  were  studied.  Bacillus  coli 
communis  and  bacillus  lactus  aerogenes 
preponderated.  Other  bacteria  when 
present  appeared  in  very  small  numbers 
and  were  apparently  insignificant.  In 
all  these  cases  bacillus  coli  preponderated 
in  the  stools  over  bacillus  lactis. 

In  another  set  of  cases,  represented  by 
six  only  of  the  ninety-two,  while  the  obli- 
gatory milk-faeces  bacteria,  were  greatly 
increased  in  number,  the  inconstant  bac- 
teria of  the  normal  intestinal  contents 
preponderated  and  appeared  to  play  an 
important  role  in  the  induction  of  the 
symptoms.  Thus,  in  three  of  the  cases 
"bacillus  a"  was  the  most  notable  feat- 
ure, and  in  one  each  "bacillus  x,"  "bacil- 
lus y,"  and  "bacillus  d."  These  are  the 
designations  applied  by  the  writer  to 
four  of  the  numerous  inconstant  milk- 
faeces  bacteria  of  infants  described  by 
him  in  a  former  paper,  several  of  which 
were  found  to  be  pathogenic  to  animals, 
and  have  since  been  shown  by  Vaughan 
to  elaborate  toxic  substances  when  grown 


8 


INFANTS,  DIARRHCEAL  DISEASES.  PATHOLOGY. 


in  broth.  These  eases  were  all  severe 
and  presented  evident  toxic  symptoms. 
The  stools  were  frequent  in  some,  in- 
frequent in  others,  and  varied  much  in 
consistence.  They  often  had  a  decidedly 
putrid  odor.  One  of  these  cases  in  which 
"bacillus  x"  preponderated  was  fatal. 

A  third  set  of  cases,  comprising  thirty- 
five,  was  characterized  by  enormous  num- 
bers of  bacilli  in  the  stools,  among  which 
proteus  vulgaris  was  always  found  in 
large  numbers.  The  ordinary  obligatory 
milk-faeces  bacteria  were  also  constantly 
present  in  very  great  excess  of  the  nor- 
mal, and  in  many  of  the  cases  a  few 
streptococci  and  some  other  inconstant 
forms  were  also  present.  These  were 
serious  cases,  usually  chronic  if  not  fatal, 
and  characterized  by  emaciation  and 
toxic  symptoms.  The  stools  were,  as  a 
rule,  liquid,  yellow  or  green  in  color, 
putrid,  and  neutral  or  alkaline  in  reac- 
tion. They  seldom,  however,  contained 
mucus,  leucocytes,  or  epithelium. 

In  the  fourth  and  last  set  of  cases, 
twenty-seven  in  number,  micrococci  pre- 
ponderated in  the  stools,  though  in  ad- 
dition bacillus  coli  was  present  in  in- 
creased number  in  all  the  cases,  bacillus 
lactis  in  fourteen,  and  proteus  vulgaris 
in  four.  The  micrococci  were  for  the 
most  part  streptococci.  These  cases 
were  uniformly  severe,  and  gave  evidence 
of  marked  toxic  disturbance.  The  stools 
were,  as  a  rule,  very  frequent,  often  more 
than  twenty  in  the  twenty-four  hours. 
They  were  soft  or  liquid,  often  greenish, 
and  usually  contained  mucus  and  leuco- 
cytes in  abundance.  They  were  also  at 
times  very  offensive.  Though  very 
numerous,  the  bacteria  were  not  present 
in  the  stools  in  the  enormous  numbers 
met  with  in  the  third  set  of  cases. 
Stained  cover-glass  preparations  also 
showed  them  to  be  chiefly  micrococci,  not 
bacilli,  as  in  the  former  cases.  A  general 
pyaemic  infection  was  a  not  infrequent 
outcome  of  these  cases.  Booker  (Johns 
Hopkins  Hosp.  Reports,  vi,  159,  '96). 

The  diarrhceal  disorders  of  childhood 
arising  under  the  influence  of  high  sum- 
mer temperature  are  at  first  only  func- 
tional in  character,  but  in  their  further 
course  profound  anatomical  alterations 
take  place  in  the  walls  of  the  stomach 


and  bowels,  which  may  range  between 
catarrh  and  necrosis  of  the  mucus  mem- 
brane. These  changes  are  attributable 
not  to  specific  bacteria,  but  to  the  ordi- 
nary saprophytic  micro-organisms  of  the 
intestinal  tract  that  assume  especial 
virulence.  The  invasion  of  other  organs 
by  these  bacteria  is  not  unusual.  The 
most  profound  disturbances  are  occa- 
sioned by  the  fermentative  products  of 
bacterial  activity,  toxic  or  non-toxic. 
Under  the  influence  of  this  intoxication 
from  the  intestinal  tract  the  resistance 
of  the  whole  organism  to  the  invasion 
of  other  pathogenic  micro-organisms  is 
diminished,  as  is  manifested  by  numer- 
ous complications.  Baginsky  (Archiv  f. 
Kinderh.,  B.  22,  113-6,  '97). 


Literature  of  '96-'97-'98. 

Conclusions  based  upon  a  study  of 
thirteen  cases  of  infantile  diarrhoea: — 

1.  The  bacterium  coli  appears  to  be  the 
pathogenic  agent  of  the  greater  number 
of  summer  infantile  diarrhoeas. 

2.  This  organism  is  the  more  often  as- 
sociated with  the  streptococcus  pyogenes. 

3.  The  virulence,  more  considerable 
than  in  the  intestine  of  a  healthy  child, 
is  almost  always  in  direct  relation  to  the 
condition  of  the  child  at  the  time  the 
culture  is  taken  and  does  not  appear  to 
be  proportional  to  the  ulterior  gravity 
of  the  case. 

4.  The  mobility  of  the  bacterium  coli 
is,  in  general,  proportional  to  its  viru- 
lence. The  jumping  movement,  never- 
theless, does  not  correspond  to  an  exalted 
virulence  in  comparison  with  the  cases 
in  which  mobility  was  very  considerable 
without  presenting  these  jumping  move- 
ments. 

5.  The  virulence  of  the  bacterium  coli 
found  in  the  blood  and  other  organs  is 
identical  to  that  of  the  bacterium  coli 
taken  from  the  intestine  of  the  same  sub- 
ject. C.  G.  Cumston  (Inter.  Med.  Mag., 
Feb.  and  Mar.,  '98). 

The  anatomical  lesions  met  with  in  the 
intestinal  tract  of  the  infant,  as  the  re- 
sult of  the  diarrhoea,  are  of  a  varied 
\  character  and  are  due  apparently  to  the 
intensity  of  the  irritant  and  the  period 


INFANTS,  DIARRHCEAL 


DISEASES.  PATHOLOGY. 


9 


of  time  during  which  its  action  has  per- 
sisted. Nevertheless,  it  must  be  acknowl- 
edged that  there  is  frequently  a  surpris- 
ing want  of  relation  between  the  post- 
mortem evidence  of  disease  and  the  se- 
verity of  the  clinical  phenomena  and 
vice  versa:  a  lack  of  relation,  which  thus 
far  pathologists  have  not  satisfactorily 
explained.  Attempts  have  been  made  at 
a  classification,  but  it  is  generally  ad- 
mitted that  although  cases  may  be 
grouped  according  to  the  prominence 
attained  by  certain  lesions,  no  distinct 
dividing  lines  can  be  drawn. 

In  the  more  acute  cases  the  lesions  are 
comparatively  superficial.  In  such/  to 
the  naked  eye,  the  stomach  and  upper 
portion  of  the  small  intestine  may  ap- 
pear almost  normal;  toward  the  lower 
end  of  the  ileum  and  throughout  the 
colon,  indications  of  inflammatory  dis- 
turbance are  to  be  seen;  as  a  rule,  they 
are  specially  pronounced  in  the  region  of 
the  sigmoid  flexure.  The  most  impor- 
tant of  these  indications  are  irregular 
patches  of  local  congestion,  and  more  or 
less  swelling  with  hyperemia  of  the  soli- 
tary glands  and  of  Peyer's  glands.  Under 
the  microscope  hardened  sections  of  the 
intestinal  wall  show,  in  places,  loss  of 
superficial  epithelium.  This  is  especially 
noticeable  toward  the  lower  portion  of 
the  ileum  and  over  the  whole  of  the 
colon,  where  a  considerable  infiltration 
of  the  mucosa  with  polynuclear  leuco- 
cytes may  frequently  be  seen.  In  some 
instances  an  invasion  of  the  mucosa  by 
bacteria  takes  place  in  areas  where  the 
epithelium  is  absent  (Booker).  These 
local  conditions  are  by  no  means  to  be 
taken  as  a  measure  of  the  general  sys- 
temic disturbance,  for  in  a  proportion  of 
cases  the  manifestations  of  an  acute  gen- 
eral infection  are  pronounced;  evidenced 
in  the  liver  by  fatty  degeneration  and 
sometimes  necroses  of  liver-cells,  in  the 


kidney  by  necrosis  of  the  epithelium  in 
the  convoluted  and  irregular  tubules,  and 
in  the  lungs  by  a  lobular  pneumonia. 

In  cases  running  a  longer  course  the 
inflammatory  changes  may  be  more  pro- 
nounced. In  a  proportion  of  these  the 
lesions  may  be  described  as  catarrhal  in 
character.  The  macroscopic  changes  are 
to  a  great  extent  confined  to  the  lower 
end  of  the  ileum  and  to  the  colon,  where 
the  congestion  is  very  pronounced,  some- 
times general,  at  other  times  localized  in 
patches;  the  lymph-nodules  are  enlarged 
and  can  frequently  be  seen  with  com- 
mencing ulceration  at  their  summit; 
Peyer's  patches  are  also  swelled  and 
hypersemic.  Under  the  microscope 
hardened  sections  from  stomach  and 
small  intestine  reveal  marked  cloudiness 
of  the  epithelial  cells  and  in  places  loss  of 
superficial  epithelium.  The  connective 
tissue  of  the  villi  and  that  supporting  the 
glands  of  Lieberkuhn  is  more  or  less 
densely  infiltrated.  The  ducts  contain 
an  excess  of  goblet-cells  and  are  dis- 
tended with  mucus.  The  loss  of  super- 
ficial epithelium  is  very  general  through- 
out the  colon.  Associated  with  it  is  a 
more  or  less  dense  infiltration  of  the  mu- 
cosa, an  infiltration  which  in  places  may 
extend  even  to  the  muscular  coat. 
Should  the  case  be  more  protracted, 
ulceration  may  supervene,  chiefly  in  the 
colon,  very  rarely  in  the  lower  portion 
of  the  ileum.  Such  ulceration  is,  for  the 
most  part,  superficial,  rarely  extending 
deeper  than  the  mucosa.  The  ulcers,  in 
general,  are  circular,  but  in  the  more 
severe  cases  several  ulcers  may  coalesce, 
forming  large,  irregular  patches,  two  to 
three  inches  in  diameter  (Holt). 

In  a  larger  group  of  cases  the  intensity 
of  the  inflammation  appears  to  fall 
chiefly  upon  the  lymph-nodules,  which, 
throughout  the  colon  and  especially  in 
the  neighborhood  of  the  sigmoid  flexure, 


10 


INFANTS,  DIARRHCEAL  DISEASES.  CLASSIFICATION. 


show  indications  of  a  destructive  inflam- 
mation. Under  the  microscope  they  are 
seen  to  be  swelled  and  infiltrated,  many 
showing  focal  necroses.  The  surround- 
ing tissues  are  deeply  infiltrated  with 
lymphoid  cells.  If  life  be  longer  pre- 
served the  follicular  tissues  break  down, 
forming  small,  but  deep,  ulcers,  with 
overhanging  edges,  exhibiting  a  tendency 
to  extend  chiefly  in  the  submucous  tissue. 
These  cases  have  very  generally  a  fatal 
issue.  In  those  cases  in  which  such  a 
termination  is  avoided  convalescence  is 
very  slow,  the  diarrhoea  assuming  a 
chronic  form,  maintained  by  the  pres- 
ence of  these  ulcers,  which,  with  diffi- 
culty, take  on  a  healing  action. 

In  a  few — fortunately  very  rare — cases 
the  inflammation  is  of  such  an  intense 
fibrinous  character  as  to  lead  to  the 
formation  of  false  membrane.  This  is 
the  most  severe  form,  and,  although  the 
pyrexia  may  be  relatively  moderate,  the 
constitutional  symptoms  are  very  grave; 
death  generally  takes  place  in  from  eight 
to  twelve  days. 

Diarrhoeal  Disorders. 

Classification. — Attempts  have  been 
made  at  a  classification  of  diarrhoeal  dis- 
orders, based  either  upon  the  changes 
found  post-mortem  in  the  intestinal 
canal  or  upon  the  bacteriological  condi- 
tions met  with  in  the  discharges,  but  in 
both  respects  our  knowledge  is  still  too 
imperfect  to  permit  us  from  it  to  draw 
dividing  lines  in  a  thoroughly  satisfac- 
tory manner.  As  physicians  we  are  able 
also  to  recognize  clinically  certain  types 
of  the  disease,  which  to  some  extent  cor- 
respond with  the  groups  that  patholo- 
gists have  attempted.  Nevertheless  we, 
too,  must  admit  that  our  clinical  types 
have  no  sharp  dividing  lines,  but,  both  in 
the  group  and  in  the  individual  patient, 
show  a  tendency  to  pass  from  the  milder 
into  the  more  severe  form. 


Two  recent  classifications,  which  rest 
partly  on  a  pathological  and  partly  upon 
a  clinical  basis,  are  worthy  of  mention. 
One  is  that  of  Lesage,  who,  in  a  very  in- 
teresting article  recently  issued  from  the 
French  press,  groups  the  acute  cases  of 
infantile  diarrhoea  into  three  classes. 

In  the  first  he  includes  all  those  which 
are  due  to  the  presence  in  the  infant's 
food,  whether  breast-milk  or  cows'  milk, 
of  irritant  substances  not  the  result  of 
fermentation  in  the  milk.  These  diar- 
rhoeas are  generally  of  a  mild  type  and 
quickly  controlled.  In  a  second  group 
are  placed  those  cases  where  the  disturb- 
ance is  due  to  fermentation  in  the  stom- 
ach or  intestinal  canal  of  indigestible  but, 
at  the  same  time,  more  or  less  sterile 
food.  The  constitutional  intoxication  in 
these  cases  is  due  to  the  abnormal  de- 
velopment of  bacteria  previously  exist- 
ing in  the  canal  (endogenous).  These 
cases,  although  sometimes  severe,  gen- 
erally run  a  comparatively  mild  course. 
The  third  and  largest  group  contains  all 
those  cases  in  which  the  diarrhoea  is  due 
to  fermental  changes  in  the  milk  admin- 
istered as  food  to  the  infant.  The  poison- 
producing  bacteria  are  thus  introduced 
from  without  (exogenous).  The  consti- 
tutional symptoms  met  with  in  this  class 
are  frequently  of  the  severest  type. 

This  classification,  although  interest- 
ing, is  scarcely  as  satisfactory  as  that 
made  by  Booker,  who  also  groups  the 
acute  cases  of  diarrhoea  met  with  during 
summer  into  three  classes.  In  the  first 
he  places  all  cases  of  a  dyspeptic  and  non- 
inflammatory character.  In  these  the 
stools  are  lumpy  and  acid  and  contain  no 
leucocytes  or  epithelial  cells;  the  bac- 
teria are  only  those  of  normal  healthy 
motions;  and  the  diarrhoea  is  of  a  milder 
form  and  for  the  most  part  easily  con- 
trolled: but,  if  neglected,  it  shows  a  tend- 
ency to  take  on  the  characters  of  one 


INFANTS,  DIARRHCEAL  DISEASES.    FUNCTIONAL  FORMS. 


11 


of  the  two  succeeding  classes.  The  sec- 
ond group  is  characterized  by  symptoms 
of  only  moderate  inflammation,  but  there 
is  present  a  well-marked  toxic  condition 
of  the  system;  the  stools  are  numerous, 
of  a  watery  or  pasty  character,  and  con- 
tain few,  if  any,  leucocytes,  but  bacilli  in 
distinctly  predominating  numbers;  sel- 
dom, however,  is  any  one  variety  so 
greatly  in  excess  as  to  exclude  the  influ- 
ence of  other  forms.  In  the  third  group 
of  cases  we  meet  with  a  distinctly  inflam- 
matory diarrhoea  associated  with  symp- 
toms of  a  general  infection;  the  stools 
are  frequent  and  slimy  and  contain  many 
leucocytes;  streptococci  are  found  in 
predominating  numbers,  although  other 
forms  of  bacteria  are  also  present.  In 
the  more  severe  cases  an  invasion  of  the 
tissues  of  the  intestinal  wall  by  the  strep- 
tococci takes  place,  and  in  many  in- 
stances more  or  less  extensive  ulceration 
of  a  suppurative  character  may  be  found 
post-mortem.  There  is,  according  to 
Booker,  a  considerable  difference  in  the 
clinical  course  run  by  the  individual  cases 
in  this  group;  some  patients  respond 
readily  to  treatment,  while  others  are 
little  influenced  and  steadily  grow  worse, 
until  the  disease  terminates  fatally. 
Booker  thinks  that  this  may  possibly  be 
due  to  the  fact  that  the  streptococci  met 
with  are  of  more  than  one  variety. 

Of  this  classification,  Booker  says  that 
in  typical  instances  the  three  forms  may 
be  easily  recognized,  but  there  are  many 
transitional  cases  which  do  not  fall  into 
any  one  of  the  three  groups  and  are  prob- 
ably due  to  a  more  mixed  infection  in 
which  no  one  bacterium  is  especially  pre- 
dominant. This  classification  of  Booker's 
corresponds  clinically  very  closely  with 
that  of  Holt,  who,  however,  lays  more 
emphasis  on  the  anatomical  post-mortem 
changes. 

To  these  groups  we  must  add  a  fourth, 


comprising  those  cases  which  assume  a 
chronic  type,  and  are  not  infrequently 
met  with  as  the  sequelae  of  one  of  the 
preceding  forms.  With  this  group,  as 
with  the  others,  we  can  draw  no  definite 
dividing-line  separating  it  sharply  from 
the  more  acute  cases.  Holt  terms  those 
cases  chronic  which  have  persisted  longer 
than  six  weeks.  Some  cases,  however, 
assume  the  type  of  chronicity  sooner, 
even,  than  this.  In  them  the  signs  of 
active  inflammation  subside,  the  appetite 
partially  returns;  the  diarrhoea,  though 
lessened,  still  persists  and  is  associated 
in  some  instances  with  a  varying  amount 
of  ulceration  of  the  intestinal  wall,  in 
others  with  a  more  or  less  atrophic  con- 
dition of  the  intestinal  glands.  In  the 
latter  variety  the  progressive  emaciation 
indicates  how  serious  is  the  interference 
with  the  processes  of  digestion  and  ab- 
sorption. 

These  somewhat  provisional  groups 
may  be  tabulated  as  follows: — 

1.  Functional  diarrhoeas,  non-inflam- 
matory in  character. 

2.  Inflammatory  diarrhoeas,  in  which 
the  symptoms  of  a  toxic  systemic  infec- 
tion are  predominant. 

3.  Inflammatory  diarrhoeas,  in  which 
in  addition  to  the  systemic  infection  the 
symptoms  of  an  acute  local  inflammation 
have  a  prominent  part. 

4.  Chronic  diarrhoeas,  in  which  the 
acute  inflammatory  symptoms  have  more 
or  less  subsided,  but  in  which  the  stools 
remain  abnormal  both  in  character  and 
frequency,  and  emaciation  is  apt  to 
supervene. 

Functional  Diarrhoeas. — Many  cases  of 
infantile  diarrhoea  are  met  with  which 
cannot  be  otherwise  regarded  than  as 
purely  functional  in  character.  During 
dentition  a  moderate  increase  in  peristal- 
sis and  secretion  is  sometimes  noted 
which  it  is  difficult  to  attribute  to  any 


12       INFANTS,  DIARRHEAL  DISEASES.    FUNCTIONAL  FORMS.  SYMPTOMS. 


fault  in  diet,  and  which  promptly  sub- 
sides on  the  eruption  of  the  teeth.  In 
a  few  instances  a  similar  condition  may 
be  induced  by  impulses  acting  through 
the  nervous  system,  such  as  fright,  over- 
excitement,  and  a  sudden  chill  to  the 
surface  of  the  body.  At  other  times 
these  same  causes  appear  to  produce  their 
effect  chiefly  by  disturbing  digestion. 
Substances  also  may  occasionally  be 
given  as  food  to  the  infant  which  act  as 
direct  mechanical  irritants  to  the  sensi- 
tive mucous  membrane  of  the  alimentary 
tract. 

In  this  group  are  also  to  be  placed 
many  diarrhoeas  met  with  in  breast-fed 
infants,  where,  owing  to  a  faulty  dietary 
or  mode  of  life,  or  to  nervous  overstrain 
on  the  part  of  the  mother  or  nurse,  the 
breast-milk  becomes  altered,  resulting  in 
either  gastric  or  intestinal  indigestion 
followed  by  diarrhoea.  The  time  of  wean- 
ing is  similarly  one  of  peculiar  suscepti- 
bility. Infants  artificially  fed  suffer 
sometimes  from  this  form  of  the  disease; 
in  them  any  error  in  the  preparation  or 
administration  of  their  food  may  be  fol- 
lowed by  an  attack  of  diarrhoea.  In  such, 
however,  these  attacks  are  more  liable 
than  in  the  breast-fed  to  assume  an  in- 
flammatory type.  This  liability  is  still 
further  increased  by  all  conditions  lower- 
ing the  digestive  powers. 

Symptoms. — In  some  instances  the 
diarrhoea  may  commence  quite  suddenly 
with  large  more  or  less  fluid  motions, 
containing,  besides  faecal  matter,  con- 
siderable undigested  material.  In  other 
cases  symptoms  of  gastric  irritation  and 
abdominal  pain  precede  for  some  hours 
the  diarrhoea.  Examination  of  the  in- 
fant generally  reveals  a  moderate  amount 
of  pyrexia:  100°  to  102°  F.;  rarely  does 
the  temperature  run  higher  except  in 
cases  of  sudden  onset  with  severe  gastric 
disturbance.    Slight  abdominal  disten- 


sion may  often  be  noted.  The  stools  are 
frequent,  thin,  usually  sour-smelling,  and 
of  varying  color.  In  young  infants  on  an 
exclusive  milk  diet,  they  are,  in  general, 
of  some  shade  of  green  and  of  a  distinctly 
acid  reaction;  occasionally,  however,  they 
are  gray  or  chalky  in  color  and  frothy  in 
character.  In  older  infants,  on  a  more 
mixed  diet,  the  stools  may  have  no  uni- 
form color,  but  be  in  part  green  and  in 
part  some  shade  of  brown,  and  of  a  very 
unpleasant  odor.  Examination  under 
the  microscope  reveals,  besides  undi- 
gested material,  only  those  forms  of  bac- 
teria met  with  in  normal  faeces.  The 
infant  is  peevish  and  may  either  refuse 
its  food  altogether  or  drink  a  part 
greedily  to  allay  its  feverish  thirst,  and 
then  refuse  the  remainder.  Should  the 
pyrexia  run  high,  nervous  symptoms 
may  manifest  themselves  in  twitching  of 
the  limbs,  prostration,  and  wakefulness. 

The  attack  in  this  type  of  the  disease 
is  of  brief  duration.  After  the  diarrhoea 
has  continued  for  some  hours  the  tem- 
perature generally  falls;  nervous  symp- 
toms, if  present,  pass  away;  the  motions 
in  a  few  days  become  less  frequent  and 
gradually  resume  their  normal  appear- 
ance; and  the  desire  for  food  becomes 
more  imperative. 

Diagnosis. — At  the  onset,  unless  from 
the  history  of  the  case,  it  is  impossible 
to  predict  with  certainty  just  what  we 
may  have  to  deal  with.  It  must  be  re- 
membered that  symptoms  similar  to  the 
above  may  not  infrequently  usher  in  a 
severe  constitutional  disorder. 

Prognosis. — Simple  functional  diar- 
rhoea, unless  in  infants  of  the  weakest 
constitution,  can  never  be  regarded  as 
presenting  much  cause  for  anxiety.  The 
danger  lies  in  neglect.  An  injudicious 
dietary,  especially  in  hot  weather,  may 
prolong  the  attack  or  convert  it  into  one 
of  the  inflammatory  forms  of  the  disease. 


INFANTS,  DIARRHEAL  DISEASES.    FUNCTIONAL  FORMS.    TREATMENT.  13 


Treatment. — In  cases  where  the  diar-  j 
rhcea  appears  to  have  removed  the  irri- 
tant it  will  suffice  to  secure  absolute  rest 
to  the  alimentary  tract  for  a  period  vary- 
ing from  twelve  to  twenty-four  hours, 
permitting  only  sterile  water  in  small 
quantities  as  frequently  as  may  be  de- 
sired. If  the  attack  has  been  of  a  mild 
character,  a  thin  rice-  or  barley-  water 
containing  a  small  amount  of  sugar  of 
milk  may  be  allowed  after  the  first  twelve 
hours  have  passed.  Stimulants  in  the 
form  of  whisky  or  brandy  are  to  be  given 
only  if  any  indications  of  prostration 
make  their  appearance.  In  the  majority 
of  cases  this  dietary  may  be  increased 
after  twenty-four  hours.  In  infants  who 
are  breast-fed  nursing  may  be  allowed 
once  every  four  or  six  hours,  permitting 
the  infant  to  take  a  little  more  than  half 
its  usual  quantity  at  each  nursing.  Rice- 
water  or  weak  albumin-water  may  be 
given  between-times.  In  those  arti- 
ficially fed  the  food  for  several  days  must 
be  weak  in  character,  and  limited  in 
amount.  A  small  quantity  of  a  creamy 
milk  may  be  added  to  the  rice-  or  barley- 
water. 

The  foods  of  greatest  value  in  the 
treatment  of  summer  complaint,  and  the 
indications  for  their  use,  considered  by 
the  writer  to  be  as  follow: — 

"Whisky,  one  of  the  most  useful,  never 
contra-indicated;  especially  useful  in 
acute  cases  during  the  last  twenty-four 
hours  of  treatment,  but  may  be  given  at 
any  time  in  either  acute  or  chronic  cases. 

"Meat-broths  contain  so  little  albumin 
and  carbohydrates  that  they  are  never 
theoretically  contra-indicated.  They 
may  be  given  at  any  time,  in  either 
acute  or  chronic  cases,  but  they  are 
especially  indicated  in  acute  cases  after 
the  first  twelve  or  twenty-four  hours' 
treatment. 

"Cream  contains  so  little  albumin  that 
theoretically  it  is  never  contra-indicated. 
It  can  do  no  harm  in  any  form  of  the 
disease,  but  it  will  be  found  to  serve  the  | 


best  purpose  in  chronic  cases,  and  after 
the  third  or  fourth  day  in  acute  cases. 

"Barley-water  and  oatmeal-water  may 
be  mixed  with  milk  to  advantage,  as 
they  mechanically  facilitate  the  digestion 
of  casein.  In  this  combination  they  may 
be  useful  in  chronic  cases  and  in  con- 
valescent acute  cases. 

"White  of  egg  is  contra-indicated  in 
all  cases  of  summer  complaint  when 
there  are  marked  constitutional  symp- 
toms present,  or  when  the  diarrhoea  is 
putrid  or  mucous,  but  it  may  be  used  in 
that  form  of  the  disease  dependent  on  an 
abnormal  acid  fermentation.  Rachford 
(Archives  of  Ped.,  No.  6,  '92). 

In  cases  of  diarrhoea  beginning  with 
very  active  symptoms,  all  food  to  be 
withheld  for  twelve  or  twenty-four 
hours.  Water  may  be  given,  or  water 
and  brandy,  or  perhaps  a  little  chicken- 
broth.  When  there  is  vomiting  every- 
thing should  be  given  cold.  When  milk 
can  be  retained  by  the  stomach,  it  is  to 
be  preferred  to  other  food,  but  must  be 
given  very  largely  diluted.  Combe  (Re- 
vue Med.  de  la  Suisse  Rom.,  Jan.  20,  '90). 

Special  attention  drawn  to  the  fact  of 
great  loss  of  water  which  these  patients 
sustain.  The  writer  allows  water  freely, 
or  chamomile-tea,  or  fennel-tea,  and  also 
uses  baths.  As  soon  as  feeding  is  begun 
at  all,  milk  is  to  be  used  at  first  in  the 
dilution  of  1  part  to  9  parts  of  water, 
gradually  increasing  the  proportion  of 
milk  to  one-quarter  or  even  one-third. 
Meinert  (Inter,  klin.  Rund.,  Sept.  28, 
'90). 

Infants  suffering  from  diarrhoea 
treated  by  withholding  the  milk  by 
which  they  are  being  fed  and  giving 
them  water  only.  Lutori  (Med.  Press 
and  Circular,  Apr.  5,  '93). 

Slightly  alkaline  and  aerated  water 
in  small  doses,  often  repeated,  adminis- 
tered, all  food  being  suppressed  from  ten 
to  eighteen  hours,  according  to  the  con- 
dition of  the  infant.  It  is  very  essential 
to  exercise  great  circumspection  in  order- 
ing the  return  to  the  ordinary  diet.  If 
the  child  is  collapsed  when  first  seen, 
subcutaneous  injections  of  water  must 
be  resorted  to.  As  soon  as  tolerated,  the 
child  is  to  receive  a  mixture  of  four-fifths 
water  and  one-fifth  sterilized  milk,'  cold 


INFANTS,  DIARRHCEAL  DISEASES. 


FUNCTIONAL  FORMS.  TREATMENT. 


bouillon,  and  albuminosed  water.  Remy 
(Gaz.  Med.  de  Strasbourg,  July  1,  '93). 

Literature  of  '96-'97-'98. 

Treatment  of  infantile  diarrhoea  by  a 
regimen  of  boiled  water,  cooled  to  a  suit- 
able temperature,  and  given  in  small 
quantities  every  hour  or  half-hour,  or  as 
thirst  demands,  to  the  exclusion  of  all 
food  for  eight,  twelve,  or  even  twenty- 
four  hours,  advocated.  Watu  (Charlotte 
Med.  Jour.,  Aug.,  '97). 

In  an  acute  attack  of  summer  diar- 
rhoea in  a  child  under  two  years  of  age  all 
albuminous  and  starchy  foods  should  be 
withheld  at  once.  Instead,  toast-water — 
made  by  laying  in  a  large  bowl  two 
pieces  of  stale  white  bread  toasted  brown 
on  both  sides,  pouring  on  boiling  water 
till  covered,  and  adding  a  pinch  of  salt 
and  allowing  to  stand  till  cool,  the  clear 
water  being  then  poured  off  into  a  fruit- 
jar  and  kept  cool  by  ice — is  excellent. 
Barley-water,  made  by  boiling  a  handful 
of  pearl  barley  in  a  pint  of  water  for  one 
hour  or  more,  a  pinch  of  salt  being 
added,  can  also  be  prepared,  and  after  it 
is  cool  the  supernatant  liquid  can  be 
poured  off  for  use.  From  one  to  three 
tablespoonfuls  of  either  of  these  foods 
can  be  given  every  hour  or  two  for  forty- 
eight  hours  if  necessary.  Alcoholic 
stimulants  may  be  added  if  necessary. 
These  drinks  should  always  be  given 
cold.  When  the  vomiting  and  stools 
have  improved,  which  usually  occurs 
within  forty-eight  hours,  nursing  may  be 
resumed  at  intervals  of  either  two,  three, 
or  four  hours.  If  sterilized  milk  be  used 
it  should  not  be  for  longer  than  the 
summer  months,  on  account  of  the  tend- 
ency to  produce  rachitis.  A  mixture  of 
cows'  milk,  diluted  one-fourth  with 
water  and  containing  a  little  milk-sugar 
and  a  pinch  of  salt,  is  to  be  preferred. 
The  prepared  milk  is  placed  into  a 
double-boiler  of  agateware,  and  the 
water  in  the  outer  vessel  is  allowed  to 
boil  for  fifteen  minutes.  The  inner  ves- 
sel is  then  rapidly  cooled,  and  the  con- 
tents poured  into  a  well-sealded  tighl 
fruit-jar,  and  kept  by  the  ice  until  re- 
quired for  use.  The  entire  quantity  re- 
quired for  use  during  the  day  can  thus 
be  prepared  at  once.    After  each  feeding 


the  child's  mouth  should  be  wiped  out 
with  a  bit  of  absorbent  cotton  soaked  in 
a  saturated  solution  of  boric  acid. 
Plenty  of  water  that  has  been  boiled  and 
cooled  should  be  given.  Dessau  (Clin. 
Recorder,  '97). 

In  the  majority  of  instances,  however, 
it  is  wiser  to  secure  at  the  outset  by 
means  of  medicine  a  thorough  evacuation 
of  the  bowels,  ridding  them  in  this  way 
of  any  fermenting  material.  To  accom- 
plish this  we  may  make  use  of  either 
castor-oil  or  calomel,  both  of  which  act 
promptly  and  with  little  irritant  effect 
on  the  mucous  membrane..  Of  the  for- 
mer a  full  dose  may  be  given  in  any  con- 
venient way.  Should  there  be  much 
gastric  irritation,  as  shown  by  a  tendency 
to  retch  or  vomit,  the  latter  is  preferable, 
and  may  be  given  in  small  doses — 1/8  to 
V4  grain,  at  short  intervals — until  a  de- 
cided effect  is  obtained.  Afterward,  if 
necessary,  one  of  the  preparations  of  bis- 
muth may  be  given  with  each  feeding, 
for  a  few  days. 

Literature  of  '96-'97-'98. 

Slight  purge  should  be  given  to  begin 
with.  If  this  fails,  enemata  of  starch- 
water  with  from  half  a  drop  to  a  drop 
of  laudanum  may  be  administered,  and 
repeated  two  or  three  times  a  day  if 
necessary.  Internally,  bismuth  or  as- 
tringents are  to  be  used.  M.  A.  F. 
Plicque  (Pract.,  Oct.,  '9G). 

In  simple  diarrhoea  the  indications 
are  to  first  remove  by  purgatives  the  irri- 
tating and  decomposing  contents  of  the 
intestines.  This  is  best  done  by  giving 
calomel  in  small  doses — say,  Vio  grain — 
frequently  repeated  or  by  a  full  dose  of 
castor-oil. 

The  second  indication  is  to  withhold 
food  which  would  be  likely  to  undergo 
fermentation  and  add  to  the  existing 
toxannia.  Milk  and  other  foods  should 
be  absolutely  prohibited.  The  child 
should  be  allowed  to  take  pure  water 
quite  freely.  Barley-water,  to  which  a 
little  white  of  egg  or  sugar  has  been 


INFANTS,  DIARRHCEAL  DISEASES 

added,  may  be  given,  and,  later,  whey 
may  also  be  given. 

Third.  If  ptomaines  are 'thought  to  be 
present  in  the  lower  bowel  it  would  be 
well  to  irrigate  after  each  movement  of 
the  bowels,  using  a  warm  normal  salt 
solution  (1  drachm  to  1  quart),  about  1 
pint  at  a  time. 

Finally,  such  drugs  as  retard  fermen- 
tation: e.g.,  bismuth  subnit.,  gr.  x,  every 
two  or  three  hours;  or  soda  benzoate  in 
4-grain  doses  in  water  every  two  hours. 
J.  Lewis  Smith  (Pediatrics,  July,  '96). 

Salicylate  of  bismuth  given  in  fifty 
cases  of  diarrhoea  in  infants  under  two 
years  of  age,  with  only  two  deaths.  The 
following  formula  is  recommended:  — 

I£  Bismuthi  salicylici,  24  grains. 
Gummi  arabici,  1  drachm. 
Sacch.  albi,  1 1/2  drachms. 

Terendo  adde  aq.  dest.,  2  ounces. 

Fiat  lac,  turn  adde  aq.  dest.,  4  ounces. 

M.  D.  S.:  The  bottle  to  be  kept  in 
cold  water  or  ice,  and  to  be  shaken  well 
before  use.  One  or  two  teaspoonfuls 
three  to  six  times  daily.  In  cases  of 
offensive  diarrhoea  the  administration 
should  be  preceded  by  a  dose  of  castor- 
oil.  In  acute  cases  the  remedy  is  useless, 
but  in  all  of  a  week's  standing  or  longer 
its  effects  are  excellent.  Mikhnevitch 
(Med.  Oboz.;  Indian  Lancet,  Aug.  1,  '97). 

Inflammatory  Diarrhoeas. — The  two 

groups  of  inflammatory  diarrhoeas  in- 
clude almost  all  the  cases  of  infantile 
diarrhoea  met  with  during  the  summer 
months.  They  are  very  closely  allied  in 
their  etiology,  and  although  the  intes- 
tinal lesions  in  the  one  are  comparatively 
slight,  while  the  symptoms  of  local  in- 
flammation in  the  other  hecome  promi- 
nent, in  both  we  have  to  deal  with 
marked  constitutional  disturbance.  All 
that  we  have  said  in  reference  to  the  in- 
fluence of  age,  of  season,  and  of  mode  of 
feeding  is  equally  true  of  both  groups. 
The  symptoms  and  course  of  these  two 
varieties  of  the  disease  differ  in  impor- 
tant particulars.  We  have  already  re- 
ferred to  their  pathology;  we  cannot  but 


INFLAMMATORY  DIARRHCEAS.  15 

feel,  however,  that  there  is  still  much 
that  is  obscure,  and  later  investigations 
may  prove  the  bacteriological  relations 
of  the  two  classes  are  even  closer  than  at 
the  present  they  appear. 

Inflammatory  Diarrhoeas  in  which 
the  Symptoms  of  a  Toxic  Systemic 
Infection  are  Predominant — Acute 
Gastro  -  Enteric  Infection  —  Acute 
Gastro-Intestinal  Catarrh. 

Symptoms. — As  we  might  be  led  to 
almost  expect,  when  we  consider  the 
various  ways  and  the  varying  numbers 
and  characters  in  which  these  toxin- 
producing  bacteria  make  their  entrance 
into  the  alimentary  tract  and  the  varying 
conditions  under  which  their  develop- 
ment may  take  place  in  the  stomach  and 
intestines,  the  mode  of  onset  of  this  dis- 
ease is  very  variable.  Frequently  it  is 
gradual;  the  symptoms  may  present 
little  except  their  persistence  to  dis- 
tinguish them  from  those  produced  by 
indigestion.  The  infant  may  be  fretful, 
show  occasional  signs  of  colic,  be  restless 
at  night,  and  slightly  feverish;  and  asso- 
ciated with  these  disturbances  may  be 
some  looseness  of  the  bowels.  As  the 
disease  progresses  the  symptoms  increase 
in  severity;  the  motions  become  fre- 
quent, thin  in  character,  and  of  a  varying 
color,  and  of  a  sour,  or  more  generally  of 
an  offensive  odor;  pyrexia  increases;  the 
pulse  becomes  quick  and  weak;  and  pain 
becomes  a  marked  feature,  interfering 
with  rest  and  sleep.  At  other  times  the 
onset  is  sudden,  frequently  with  severe 
gastric  disturbance,  high  fever,  and 
sometimes  alarming  nervous  symptoms. 
In  these  cases  vomiting  is  one  of  the 
earliest  symptoms,  and  may  continue  in 
the  most  persistent  manner;  the  tem- 
perature may  be  very  high,  104°  to  105°, 
but  generally  falls  one  or  two  degrees 
after  diarrhoea  sets  in;  twitching  of  the 


16         INFANTS,  DIARRHEAL  DISEASES.    INFLAMMATORY  TOXIC  FORMS. 


limbs,  great  restlessness,  and  sometimes 
delirium,  or  even  convulsions,  may  usher 
in  the  attack.  When  the  disease  is  well 
established,  the  symptoms  become  very 
characteristic;  the  infant  is  restless,  cry- 
ing frequently;  the  face  is  pale  and  its 
features  somewhat  pinched;  the  eyes 
sunken;  the  tongue  coated  in  the  centre, 
but  with  tip  and  edges  red  and  dry; 
thirst  is  pronounced,  but  fluids  are  fre- 
quently vomited  shortly  after  they  are 
taken;  the  abdomen  is  generally,  but  not 
always,  distended.  Often  we  may  dis- 
tinguish through  the  thin  abdominal 
wall  special  dilatation  of  the  stomach  or 
small  or  large  bowel;  the  skin  gradually 
assumes  a  dry  harsh  feeling,  while  the 
subcutaneous  tissues  waste  rapidly;  the 
temperature  varies  from  102°  F.  in  the 
morning  to  103°  F.  or  more  in  the  even- 
ing, and  the  quick  and  feeble  pulse  indi- 
cates great  exhaustion. 

While  the  stools  may  at  first  contain 
some  undigested  matter,  this  soon  in 
great  part  ceases,  and  they  become  of  a 
greenish,  greenish-yellow,  or  brown  color, 
and  of  an  offensive  odor,  and  are  asso- 
ciated with  a  large  amount  of  flatus. 
Little  useful  diagnostic  information  can 
be  gained  from  their  appearance,  but  we 
may  generally  consider  that  frequent  and 
watery  stools  indicate  a  severe  attack. 
The  reaction  is  in  the  beginning  always 
acid,  but  in  the  more  severe  cases  be- 
comes neutral  or  even  alkaline.  Lesage 
says  that  a  relation  generally  exists  be- 
tween the  character  of  the  reaction  and 
the  degree  of  infection.  Under  the 
microscope  the  stools  are  seen  to  contain 
undigested  food,  epithelial  cells,  few  if 
any  leucocytes,  and  numerous  bacteria, 
among  which  bacilli  predominate. 
Vomiting  at  the  first  may  be  violent  and 
persistent,  but,  as  the  case  progresses,  the 
tendency  for  it  is  to  subside.  Pain  to  a 
greater  or  less  extent  is  always  present,  j 


In  the  earlier  days  it  is  a  prominent 
feature;  while  later  on,  perhaps  owing  to 
general  exhaustion,  the  infant  appears  to 
suffer  less  acutely.  Exacerbations  may 
be  noticed  shortly  before  each  evacua- 
tion. The  presence  of  abdominal  tender- 
ness is  generally  a  difficult  matter  to 
ascertain. 

With  these  local  symptoms  the  indica- 
tions of  a  toxic  infection  of  the  system 
are  not  wanting;  the  temperature  re- 
mains moderately  high,  101°  to  103°  F., 
with  a  tendency  to  rise  in  the  evening 
and  fall  again  toward  morning;  the  pulse 
is  quick,  and  may  become  weak  and  in- 
termittent; emaciation  goes  on  rapidly; 
with  a  greatly  increased  loss  of  fluid  in 
the  alvine  evacuations,  the  urine  becomes 
scanty  and  high-colored,  and  contains  a 
large  amount  of  indican.  As  the  disease 
progresses  to  an  unfavorable  termination, 
the  general  prostration  increases,  the  ex- 
tremities become  cold,  slightly  cyanosed, 
and  sometimes  cedematous,  and  the 
slightly-swelled  eyelids  only  half-close 
over  the  deep-sunken  eyes;  the  fonta- 
nels, if  still  open,  is  much  depressed; 
the  infant  ceases  to  cry,  and  death 
closes  the  scene  generally  in  a  very  quiet 
manner. 

Complications. — In  the  more  severe 
cases  complications  are  frequently  met 
with.  In  a  large  proportion  more  or  less 
bronchial  catarrh  is  present  by  the  end 
of  the  first  week.  Fenwick  states  that  in 
87  per  cent,  of  his  cases  signs  of  bron- 
chitis were  present  at  the  end  of  the 
fourth  da}',  and  lobular  consolidation 
was  encountered  in  nearly  37  per  cent,  of 
his  entire  number.  The  onset  of  bron- 
cho-pneumonia is  often  very  insidious; 
the  cough  may  be  only  slight,  but  the 
respirations  will  be  observed  to  be  un- 
duly frequent,  and  the  temperature 
shows  a  distinct  rise.  The  physical  signs 
are  generally  obscure,  and  most  fre- 


INFANTS,  DIARRHCEAL  DISEASES.    INFLAMMATORY  TOXIC  FORMS. 


17 


quently  are  localized  at  the  base  of  the 
lungs. 

Percussion  may  show  only  a  slight 
deficiency  in  resonance,  and  on  auscul- 
tation we  may  find  either  a  diminution 
of  vesicular  murmur  or  the  presence  of 
sibilant  rales.  It  is  characteristic,  how- 
ever, of  this  form  of  infection  that  these 
signs  are  variable,  and  show  a  tendency 
to  change  from  one  place  to  another;  it 
is  exceptional  to  observe  large  areas  of 
consolidation.  The  progress  of  the  pul- 
monary lesion  is  modified  by  the  gen- 
eral symptoms  of  the  case;  increased 
dyspnoea  is  always  a  symptom  of  grave 
import. 

Pleurisy  is  very  seldom  observed;  when 
it  does  manifest  itself,  it  tends  rapidly  to 
become  purulent.  Associated  sometimes 
with  the  pulmonary  infection,  but  occa- 
sionally as  a  complication  by  itself,  we 
meet  with  symptoms  of  cerebral  conges- 
tion, manifested  in  stupor,  delirium,  or 
epileptiform  convulsions.  Only  rarely 
do  we  observe  definite  signs  of  local 
trouble;  such  as  strabismus,  inequality 
of  pupils,  and  irregular  pulse  and  res- 
piration. Lesage  makes  reference  to 
some  forms  of  paralysis  which  disappear 
with  returning  health.  Thrombosis  of 
the  cerebral  vessels  may  take  place  in  the 
final  stages,  and  may,  or  may  not  mani- 
fest its  presence  by  special  symptoms. 
Occasionally  an  attack  of  tetany  may 
supervene.  Should  the  drain  of  fluid 
from  the  tissues  have  been  great,  the  de- 
fective circulation  may  in  itself  give  rise 
to  many  of  the  above  symptoms.  Infre- 
quently the  cerebral  symptoms  may  be 
regarded  as  of  a  ursemic  nature. 

A  true  parenchymatous  nephritis  due 
to  infection  would  appear  to  be  a  rare 
complication.  Kjellberg  states  he  met 
with  it  in  47  per  cent,  of  his  fatal  cases; 
but  competent  observers,  both  English 
and  American,  have  failed  to  meet  with 


it,  except  very  occasionally.  Fenwick 
states  that  albumin  in  the  urine  was 
noted  in  17  per  cent,  of  his  cases  before 
the  fifth  day  of  the  disease;  but  in  no 
instance  did  the  urine  show  more  than  a 
trace  of  it.  Under  the  microscope  he 
never  observed  either  blood-corpuscles  or 
epithelial  casts.  Booker  states  that  ne- 
crosis of  the  epithelium  in  the  convoluted 
and  irregular  tubules  was  found  in  nearly 
all  his  cases,  and,  in  not  a  few,  hyaline 
tube-casts  were  demonstrable.  Infiltra- 
tion with  leucocytes  was  not  seen  in  any 
case. 

Various  rashes  on  the  skin  may  occa- 
sionally be  noted,  usually  of  an  erythem- 
atous nature;  and,  unless  great  care  is 
exercised,  a  mycotic  ulceration  of  the 
mouth  and  throat  may  add  greatly  to  the 
infant's  discomfort. 

Diagnosis. — "While  there  may  be  for 
the  first  two  or  three  days  some  uncer- 
tainty in  reference  to  the  character  of  a 
diarrhoea,  a  persistent  high  temperature 
beyond  this  period  stamps  the  attack  as 
of  an  inflammatory  nature.  After  this 
date  fluid  evacuations  of  an  offensive 
odor  are  characteristic  of  the  toxic  form; 
while  small  stools  containing  mucus  in 
quantity  and  passed  with  much  straining 
are  met  with  in  those  cases  in  which  the 
local  inflammatory  disorder  is  prominent. 
Typhoid  fever  is  seldom  met  with  during 
infancy;  its  onset  is  occasionally  some- 
what abrupt,  but  after  the  first  few  days 
its  course  becomes  more  characteristic. 
Widal's  test  should  be  applied  in  doubt- 
ful cases.  Several  of  the  acute  specific 
fevers  are  sometimes  ushered  in  by  an  in- 
testinal disturbance,  which  may  for  two 
or  three  clays  be  misleading;  of  these 
scarlet  fever  and  pneumonia  are  probably 
the  most  important.  Intussusception 
develops  rapidly  and  the  stools  always 
contain  mucus  and  a  considerable 
amount  of  dark  blood,  and  are  passed 


4—2 


18         INFANTS,  DIARRHEAL  DISEASES. 

with  straining;  for  the  first  few  days 
there  is  no  pyrexia. 

Prognosis. — In  every  attack  of  inflam- 
matory diarrhoea  the  prognosis  must  be 
greatly  dependent  upon  our  securing 
from  the  outset  fair  hygienic  conditions, 
and  the  strict  observance  of  such  dietetic 
rules  as  may  be  laid  down.  In  no  dis- 
ease is  the  prognosis  more  affected  by  a 
faulty  hygiene  or  by  an  imprudent  diet- 
ary. In  infants  suffering  from  chronic 
dyspeptic  troubles,  or  in  those  whose  nu- 
trition is  seriously  impaired,  the  progno- 
sis must  always  be  grave.  During  the 
heat  of  summer  an  attack  of  inflamma- 
tory diarrhoea  is  of  much  more  serious 
import  than  one  occurring  during  the 
cooler  months  of  the  year.  In  the.  course 
of  an  attack  a  decrease  in  the  tempera- 
ture and  in  the  frequency  of  the  stools 
are  favorable  symptoms,  especially  when 
associated  with  an  improvement  in  the 
general  appearance,  an  increase  in  the 
amount  of  urine,  and  perhaps  an  in- 
creased desire  for  food.  On  the  other 
hand,  a  higher  temperature,  more  fre- 
quent and  more  watery  movements,  a 
more  anxious  expression  on  the  features, 
increasing  insensibility  of  the  pupils, 
sighing  and  irregular  respiration,  a  feeble 
and  intermittent  pulse,  suppression  of 
the  urine,  and  the  onset  of  nervous  symp- 
toms must  all  be  regarded  as  of  grave 
significance. 

Treatment. — Regarding  this  disorder 
as  due  to  an  intoxication  of  the  system, 
either  induced  suddenly  by  an  absorption 
from  the  intestinal  tract  of  toxins  in 
large  amount,  or  coming  on  gradually, 
owing  to  the  development  in  the  intes- 
tinal canal  of  pathogenic  bacteria  with  a 
subsequent  absorption  of  toxins,  our  first 
efforts  should  be  directed  to  securing  as 
promptly  and  as  effectually  as  possible 
the  clearing  out  of  the  intestinal  tract. 
This  we  endeavor  to  effect  by  means  of 


INFLAMMATORY  TOXIC  FORMS. 

promptly  acting  purgatives,  and  by  lav- 
age of  the  stomach  and  large  intestines; 
the  small  intestines,  unless  by  means  of 
purgatives,  we  are  apparently  unable  to 
reach. 

At  the  same  time  we  endeavor  to  limit 
the  development  of  bacteria  by  stopping 
for  several  days  absolutely  all  milk  food, 
in  which  we  know  they  are  able  to  de- 
velop very  rapidly;  a  sterile  water  only 
should  be  allowed  as  a  drink  for  the  first 
twenty-four  hours.  During  the  early 
days  no  astringent  or  drug  which  would 
tend  to  check  peristalsis,  at  this  period 
to  be  regarded  as  salutary  in  character, 
is  to  be  given.  For  the  evacuation  of  the 
intestinal  tract  two  drugs  especially  com- 
mend themselves,  on  account  of  their 
promptness  and  of  the  very  slight 
amount  of  irritation  which  they  induce. 
These  are  castor-oil  and  calomel. 

Castor-oil  is  of  much  value  if  it  can  be 
retained  in  the  stomach.  A  full  dose,  1 
or  2  drachms,  may  be  given  in  any  con- 
venient way.  In  many  cases  there  is  too 
great  irritability  of  the  stomach  for  us  to 
attempt  the  administration  of  this 
somewhat  nauseous  drug,  and  we  can 
with  advantage  have  recourse  to  calomel, 
which  acts  not  only  as  a  purgative,  but 
also  as  an  intestinal  antiseptic.  This 
drug  may  be  given  either  in  one  full  pur- 
gative dose,  or  in  a  series  of  small  doses 
repeated  at  short  intervals.  Lesage 
recommends  that  if  the  onset  is  with 
high  fever,  a  foul-smelling  but  not 
abundant  diarrhoea,  and  a  considerable 
amount  of  tympanites,  a  dose  of  about  1 
grain,  for  an  infant  of  three  months,  2 
grains  for  an  infant  under  one  year,  and 
3  grains  for  an  infant  over  that  age, 
should  be  administered,  mixed  with  a 
little  sugar  in  a  powder.  In  those  cases 
where  the  fever  is  only  moderate,  where 
the  abdomen  is  soft  and  not  distended, 
and  the  diarrhoea  is  copious,  small  doses 


INFANTS,  DIARRHCEAL  DISEASES.    INFLAMMATORY  TOXIC  FORMS.  19 


of  about  1/5  grain  may  be  given  every 
one  or  two  hours,  for  six  or  twelve  doses. 
Other  purgatives  have  been  employed, 
but,  in  our  opinion,  they  are  not  so  satis- 
factory. 

Beneficial  results  obtained  with  the  I 
biniodide  in  Wgrain  doses,  usually  in  a  | 
solution  of  iodide  of  potassium.  Of 
eighty  cases  of  acute  infantile  diarrhoea 
treated  by  this  method,  in  72  the  diar- 
rhoea was  cured  in  two  days.  Luff  (Brit. 
Med.  Jour.,  Nov.  16,  '88). 

[Great  benefit  obtained  from  use  of 
biniodide  of  mercury,  particularly  in  the 
green  diarrhoea  of  infants.  C.  R.  Illing- 
worth,  Collaborator,  Annual,  '90.] 

Should  vomiting  persist,  a  careful 
lavage  of  the  stomach  will  often  at  this 
period  of  the  disease  prove  of  much 
value,  not  only  removing  fermenting 
material  and  toxins,  but  having  a  direct 
action  on  the  gastric  mucous  membrane. 
This  lavage  can  easily  be  accomplished 
by  means  of  a  few  feet  of  rubber  tubing, 
to  which  is  attached  at  one  end  a  soft- 
rubber  catheter,  number  15  or  18  Eng- 
lish (No.  30  Charriere),  and  to  the 
other  a  small  glass  funnel.  The  fluid 
used  may  be  either  sterile  water  or  nor- 
mal saline  solution,  7  per  1000.  Its 
temperature  should  be  about  100°  F. 

Three  or  4  ounces  should  be  intro- 
duced at  a  time  and  allowed  to  escape. 
This  should  be  repeated  until  the  water  ! 
returns  clear. 

Literature  of  '96-'97-'98. 

Water  is  one  of  the  poorest  media  for 
the  development  of  bacteria  which  it  is 
safe  to  introduce  into  the  stomach.  If 
a  child  is  given  from  10  to  12  ounces  of  ! 
sterilized  water  daily  vomiting  will  cease 
at  once,  diarrhoea  will  soon  disappear, 
and  the  temperature  will  fall  so  that  in 
a  relatively  short  time  milk  can  again 
be  given.  Absolutely  no  medicine  will 
be  required.  Most  brilliant  results 
obtained  from  this  simple  treatment  of 
infantile  diarrhoea.  Mongour  (Corres.  f. 
Schweizer  Aerzte,  Apr.,  '98). 


Occasionally  one  of  the  milder  anti- 
septics is  added  to  the  solution;  we  are 
convinced,  however,  that  using  them  in 
this  way,  either  for  lavage  of  the  stomach 
or  lavage  of  the  intestines,  the  risk  of 
absorption  of  an  overdose  more  than 
counterbalances  any  possible  advantage. 

Thirteen  cases  of  diarrhoea  with  gas- 
tric disturbances  treated  by  stomach- 
washing,  8  of  which  were  cured  without 
the  use  of  drugs.  Darrell  (North  Caro- 
lina Med.  Jour.,  Aug.,  '91). 

A  few  hours  after  the  administration 
of  the  purgative,  an  effort  should  be 
made  to  wash  out  the  colon.  The  infant 
at  the  first  should  be  placed  on  its  back 
with  its  hips  well  elevated,  and  a  normal 
saline  solution  at  a  temperature  of  98°  F. 
be  allowed  to  flow  slowly  into  the  intes- 
tines through  a  large-sized  rubber  cathe- 
ter introduced  for  six  or  eight  inches. 
The  pressure  in  the  tube  should  be  slight, 
the  reservoir  not  being  higher  than 
twelve  inches  above  the  hips  of  the  pa- 
tient. If  the  hips  are  sufficiently  ele- 
vated a  little  gentle  massage  over  the 
region  of  the  sigmoid  flexure  secures  the 
free  passage  of  the  fluid  into  the  descend- 
ing colon,  and  afterward,  turning  the  in- 
fant on  its  right  side,  favors  its  entrance 
into  the  transverse  and  ascending  colon. 
Should  there  be  much  pyrexia  after  the 
current  has  been  once  established,  the 
temperature  of  the  water  may  be  lowered 
10°  or  15°.  Lower  than  this  has  been 
recommended  by  some  physicians,  but 
the  very  interesting  experiments  of  Dr. 
R.  Coleman  Kemp  warn  us  that  we  may 
in  this  way  produce  too  much  depression. 
The  injection  should  be  continued  until 
the  water  returns  clear.  If  done  care- 
fully, the  pulse  after  the  injection  should 
evidence  more  strength,  the  blood-pres- 
sure should  1)0  raised,  not  depressed. 
Afterward  a  cool  or  warm  compress — 70° 
to  100°  F. — applied  over  the  abdomen 


20         INFANTS,  DIARRHCEAL  DISEASES. 


INFLAMMATORY  TOXIC  FORMS. 


and  covered  with  oiled  silk  and  a  flannel 
binder  soothes  and  assuages  the  pain. 
This  lavage  of  the  intestines  may  be  re- 
peated every  six  or  twelve  hours  for  the 
first  two  or  three  days;  afterward  less 
frequently. 

The  following  treatment  has  proved 
most  successful:  — 

The  stomach  and  bowels  should  be 
freed  of  all  food,  mucus,  etc.,  by  lavage, 
introducing  an  ordinary  catheter  (soft, 
flexible,  No.  10)  attached  to  a  fountain- 
syringe,  and  using  about  1  quart  of  luke- 
warm water  in  which  is  dissolved  1  tea- 
spoonful  of  boric  acid  or  salt, — sodium 
chloride.  In  irrigating  the  bowel  it  is  a 
good  plan  to  use  Tiemann's  rectal  tube, 
introducing  it,  with  a  little  vaselin,  into 
the  rectum,  and  gently  pressing  it  up- 
ward through  the  internal  sphincter. 
The  intestines  are  irrigated  with  the 
solutions  mentioned  above,  until  the  dis- 
charges from  the  bowels  are  clear.  This 
mechanical  treatment  is  then  followed 
by  salicylate  of  bismuth,  3  to  10  grains 
every  two  or  three  hours. 

If  the  child  is  over  six  months  old,  it 
is  wise  in  all  diarrhoeas  to  discontinue 
the  breast  and  give  the  child  barley-  or 
rice-  gruel.  Raw  scraped  steak  and 
beef-blood  are  recommended.  Louis 
Fischer  (The  Post-graduate,  Sept.,  '92). 

Fifty  children  under  two  years  of  age 
have  been  treated,  at  the  New  York  Dis- 
pensary, by  irrigation  of  the  colon  and 
regulation  of  the  diet,  without  medicine. 
These  fifty  have  not  been  picked  cases. 

The  majority  (66  per  cent.)  were  re- 
lieved by  one  irrigation;  some  received 
two  and  a  few  three  irrigations.  A  small 
proportion  (20  per  cent.)  received  addi- 
tional treatment.  One  case  died  on  the 
third  day  after  being  so  treated.  Hud- 
dleston  (Med.  Rec,  Sept.  9,  '93). 

Fifty  children  under  two  years  of  age 
treated  by  irrigation  of  the  colon  and 
regulation  of  the  diet,  without  medicine. 
Sixty-six  per  cent,  were  relieved  by  one 
irrigation;  some  received  two  and  a  few 
three  irrigations.  Twenty  per  cent,  re- 
ceived additional  treatment.  Two  quarts 
of  6-per-cent.  salt  solution  are  used  at  a 
temperature  of  68°  to  75°  F.  (20°  to 
23.9°  C).   A  No.  12  catheter  is  passed  as 


far  as  possible  into  the  colon.  Huddle- 
ston  (Med.  Rec,  Sept.  9,  '93). 

Most  desirable  position  for  injection  is 
the  dorsal,  with  the  thighs  flexed  and 
the  pelvis  elevated  and  a  pressure  of  not 
more  than  one  to  one  and  one-half  metres. 
In  200  patients  experimented  upon  ileo- 
cecal valve  offered  effectual  resistance  in 
only  27.  Sokolow  (Amer.  Jour.  Med. 
Sci.,  Apr.,  '95). 

Intestinal  lavage  with  warm,  boiled 
water,  Vichy  water  being  added.  Infant 
lying  on  the  side,  first  the  right,  then  the 
left;  tube  inserted  15  centimetres  and 
water  slowly  introduced.  If  discharges 
fcetid,  calomel;  also  1  drop  of  laudanum 
every  hour.  If  obstinate,  vomiting,  lav- 
age of  stomach  and  egg-albumin  in  water 
given.  Grancher  (Revue  Gen.  de  Clin,  et 
de  Ther.  Jour,  des  Prat.,  May  18,  '95). 

Literature  of  '96-'97-'98. 

In  infectious  diarrhoea  in  infants,  the 
food-supply  is  to  be  stopped,  the  products 
of  imperfect  digestion  removed  from  the 
intestinal  tract  by  irrigation,  continued 
until  the  water  returns  free  from  ad- 
mixture of  faecal  matter.  A  solution  of 
20  grains  of  tannic  acid  in  a  pint  or 
more  of  sterilized  water  injected  and  re- 
tained in  the  bowel  about  an  hour. 
When  vomiting  persists  the  stomach 
should  be  washed  out  also.  To  neutral- 
ize the  toxins  calomel  in  Vio-grain  doses 
hourly  for  the  first  twenty-four  hours  is 
recommended.  First  among  antipyretics 
is  the  cooled  bath.  When  watery  dis- 
charges continue  after  the  irrigation,  hyp- 
odermics of  Vioo  grain  of  morphine  and 
Vsoo  grain  of  atropine  can  be  given.  Stim- 
ulants are  indicated  in  the  severe  cases, 
and  whisky  is  the  best  that  can  be  given. 
After  the  urgent  symptoms  have  sub- 
sided the  child  can  be  nourished  with  the 
white  of  an  egg  stirred  in  cold  water  or 
the  mixture  recommended  by  Jacobi: 
5  ounces  of  barley-water,  the  white  of  1 
egg,  1  or  2  teaspoonfuls  of  brandy  or 
whisky,  some  salt,  and  sugar.  A  tea- 
spoonful  every  five  or  ten  minutes  is  in- 
dicated. No  milk  should  be  given  for 
several  days.  H.  M.  McQanahan  (Amor. 
Jour.  Obstet.  and  Dis.  Women  and  Chil- 
dren; Med.  Rec,  Sept.  26,  '96). 


INFANTS,  DIARRHCEAL  DISEASES. 


CHRONIC  DIARRHOEA.    ETIOLOGY.  21 


Many  physicians  at  this  period  advo- 
cate strongly  the  administration  of  some 
drug  which  may  act  as  an  intestinal  anti- 
septic. Among  the  more  important  of 
these  drugs  we  may  mention  resorcin, 
menthol,  thymol,  bismuth  salicylate, 
sodium  salicylate,  benzol-naphthol,  and 
others. 

It  is  not  to  be  forgotten,  however,  that 
many  of  these  drugs  are  very  distinct 
cardiac  depressants,  and  we  are  con- 
vinced that  we  have  seen  many  instances 
in  which  they  have  been  employed  with 
too  much  freedom,  to  the  disadvantage 
of  the  patient;  at  the  same  time  it  is 
questionable  of  how  much  practical  value 
they  are.  Under  this  treatment  the  py- 
rexia will  be  found  to  slowly  subside,  and 
the  frequency  and  character  of  the  stools 
to  alter  for  the  better.  At  this  stage 
some  of  the  milder  astringents  may  be 
of  service.  Among  the  most  frequently 
employed  are  the  salts  of  bismuth:  the 
subnitrate,  the  salicylate,  and  the  subgal- 
late.  These  may  be  given  in  full  doses, 
suspended  in  mucilage  with  some  aro- 
matic water.  Tannigen,  a  new  astrin- 
gent, having  also  distinct  antiseptic 
properties,  may,  after  all  the  inflamma- 
tory symptoms  have  subsided,  be  of  serv- 
ice. It  may  be  given  in  a  powder,  com- 
bined with  a  little  sugar,  in  doses  of  from 
4  to  6  grains. 

The  disorder  always  commences  in  the 
stomach,  and  is  most  easily  controlled  by 
carbolic  acid.  But  its  hot  taste  and  un- 
pleasant smell,  as  well  as  the  occasional 
occurrence  of  carboluria,  rendered  its  use 
unpleasant.  Resorcin  is  extremely  pal- 
atable to  children ;  and  is  devoid  of  toxic 
properties  when  given  in  doses  from  1  to 
5  grains.  Three  grains  given  every  four 
hours  to  infants  only  a  few  weeks  old 
without  the  least  ill-effects. 

In  a  hundred  and  twenty  cases  of  in- 
testinal dyspepsia  in  infants  and  young 
children  this  treatment  was  used  with 
the  following  results:  In  53  per  cent,  the 


disorder  had  lasted  from  one  to  two 
weeks,  in  34  per  cent,  from  two  to  four 
weeks,  in  10  per  cent,  from  four  to  eight 
weeks,  and  in  the  remaining  3  per  cent, 
for  a  period  of  more  than  two  months. 
Out  of  the  entire  number  in  only  nine  in- 
stances did  the  diarrhoea  continue  after 
the  treatment  had  been  pursued  for  a 
week,  the  majority  ceasing  within  three 
days.  W.  Soltau  Fenwick  (Brit.  Med. 
Jour.,  Dec.  21,  '95). 

For  diarrhoea  with  offensive  stools  1/2 
drop  of  creasote  in  chloroform-water 
every  hour  or  two  has  been  most  satis- 
factory. Butterfield  (Med.  World,  June, 
'90). 

Literature  of  '96-'97-'98. 

In  diarrhoea  associated  with  very 
foetid  motions  the  greatest  benefit  seen 
to  follow  the  administration  of  creasote. 
W.  H.  Dickinson  (Lancet,  Mar.  28,  '96). 

Tannigen  followed  by  excellent  results 
in  the  diarrhoea  of  children  especially  in 
the  catarrhal  variety.  It  passes  through 
the  mouth  and  stomach  as  an  insoluble 
powder.  It  is  dissolved  in  the  intestinal 
canal  at  all  places  where  an  alkaline  re- 
action prevails  and  exerts  its  astringent 
effect. 

To  obtain  positive  results  tannigen 
must  be  prescribed  in  large  doses,  4 
grains  to  infant  up  to  one  and  one-half 
years,  and  7  V2  grains  to  olde^  children, 
four  to  six  times  daily.  Escherich 
(Therap.  Woch.,  Mar.  9,  '96). 

Tannigen  successfully  employed  in 
twenty-eight  cases  of  diarrhoea.  Sixteen 
of  the  patients  had  acute  gastro-enteritis, 
and  eleven  chronic  diarrhoea.  In  all  of 
the  acute  cases  but  one  the  remedy  acted 
promptly.  In  the  cases  of  chronic  diar- 
rhoea, all  of  which  were  under  one  year 
of  age,  tannigen  gave  excellent  results. 
Diarrhoea,  of  several  months'  duration, 
which  had  resisted  other  remedies, 
yielded  with  wonderful  rapidity.  Strauss 
(Berl.  klin.  Woch.,  No.  3,  '96). 

Chronic  Diarrhoea. 

Etiology. — The  chronic  form  of  diar- 
rhoea is  met  with  either  as  the  result  of  a 
previous  acute  attack  or  arising  in  an  in- 


22       INFANTS,  DIARRHEAL  DISEASES.    CHRONIC  DIARRHCEA.  SYMPTOMS. 


sidions  manner  from  prolonged  irrita- 
tion of  the  intestinal  canal  by  ill-digested 
and  more  or  less  fermenting  food. 

In  the  majority  of  those  cases  in  which 
it  follows  an  acute  attack  we  have  to  deal 
with  more  or  less  definite  organic  lesions 
present  in  the  alimentary  tract.  In  some 
the  persistent  diarrhoea  is  due  to  ulcer- 
ation of  the  intestinal  wall,  generally 
follicular,  but  occasionally  catarrhal,  in 
character.  In  others  a  more  or  less 
atrophic  condition  of  the  tubular  glands 
and  villi  in  the  small  intestines,  associ- 
ated with  marked  cell-proliferation  in 
the  adenoid  tissue  of  the  mucosa  (Holt), 
is  present.  In  a  few  instances  the  consti- 
tution of  the  infant  has  been  so  pro- 
foundly impaired  during  the  acute  attack 
that  the  various  systemic  functions  are 
re-established  with  difficulty.  Digestion 
continues  to  be  imperfectly  performed; 
and  fermentation  with  development  of 
toxins  takes  place  to  an  irregular  extent. 
This  slight,  but  continued,  systemic  in- 
toxication manifests  itself  in  ansemia,  de- 
fective general  nutrition,  and  an  irritable 
nervous  system. 

Symptoms. — The  cases  of  chronic 
diarrhoea  form  a  considerable  proportion 
of  the  diarrhoeas  met  with  during  the 
autumn.  In  such,  the  symptoms  of  acute 
inflammation  have  to  a  great  extent  sub- 
sided; the  temperature  remains  for  the 
greater  portion  of  the  .day  normal,  and 
sometimes  falls  even  below  the  normal 
line;  and  pain  and  tenderness  have  al- 
most entirely  passed  away;  but  the  mo- 
tions still  remain  too  frequent;  their  odor 
is  offensive;  blood  is  occasionally  seen  in 
the  form  of  minute  dark  specks;  and 
mucus  of  a  greenish  or  brownish  color  is 
still  present  in  considerable  amount.  The 
consistence  and  color  of  the  stools  is 
variable.  At  one  time  they  are  of  nearly 
normal  consistence  and  fairly  homo- 
geneous; at  other  times  they  are  quite 


fluid.  They  are  usually  associated  with 
much  flatulence.  Prolapse  of  the  bowel 
occurs  only  occasionally. 

The  infant's  appetite  appears  very 
variable,  but  a  fair  amount  of  nourish- 
ment is  generally  taken  during  the 
twenty-four  hours.  Vomiting  is  infre- 
quent. Nevertheless  the  infant  remains 
pale  and  weak,  and  lies  in  a  helpless  and 
apathetic  manner.  As  the  disease  pro- 
gresses nutrition  steadily  fails.  The  in- 
fant ceases  to  grow.  A  gradual  loss  in 
weight  occurs  through  wasting  of  the 
subcutaneous  tissues  till  the  inelastic  skin 
hangs  in  folds  over  the  shrunken  limbs. 
In  many  cases  the  abdomen  may  be  some- 
what distended,  but  in  others  it  is  soft 
and  retracted.  The  liver  and  spleen  are 
found  of  normal  size.  The  mesenteric 
glands,  although  in  post-mortem  exami- 
nations they  are  seen  to  be  enlarged,  are 
not  palpable.  Occasionally  petechial 
spots  are  seen  either  on  the  abdominal 
wall  or  on  the  extremities.  The  circula- 
tion in  these  infants  is  very  feeble.  The 
extremities  are  always  cold,  sometimes 
cyanotic,  and  occasionally  ©edematous. 
The  urine  is  scanty.  The  nervous  system 
suffers  with  the  general  failure  in  nutri- 
tion. The  infant  is  peevish,  easily  dis- 
turbed, and  sleeps  badly  at  night. 

The  progress  of  these  cases  is  by  no 
means  uniform.  Some  weeks  may  show 
a  slight  gain;  but  trivial  causes,  a  chill 
to  the  surface  of  the  body,  or  a  slight 
irregularity  in  feeding,  may  bring  on  a 
relapse,  and  the  gain  is  usually  soon  lost. 

Complications  frequently  arise.  Bron- 
chitic  or  pneumonic  symptoms  may  ap- 
pear in  the  lungs.  Rachitis  frequently 
develops.  Sometimes  we  have  a  general 
adenitis,  or  a  still  more  distressing  fnrun- 
culosis.  Only  very  rarely  is  nephritis  en- 
countered. 

A  fatal  termination  is  frequently  has- 
I  tened  by  some  intercurrent  disease;  at 


INFANTS,  DIARRHEAL  DISEASES.    CHRONIC  DIARRHCEA.    DIAGNOSIS.  23 


other  times  it  advances  very  slowly  and 
the  ending  comes  so  gently  that  the  ex- 
act moment  of  death  is  unascertainable. 
In  a  few  cases,  however,  the  appetite 
gradually  returns,  the  stools  become 
more  normal,  nutrition  gradually  im- 
proves, and  at  last  convalescence  is 
thoroughly  established. 

In  the  second  class  of  cases  this  chronic 
form  of  diarrhoea  establishes  itself  with- 
out any  preceding  acute  attack.  Eustace 
Smith  considers  that  in  the  majority  of 
these  cases  the  affection  is  due  to  re- 
peated drillings  of  the  surface  of  the 
body,  producing  a  catarrhal  condition  of 
the  gastro-intestinal  tract.  Another  im- 
portant factor  is  undoubtedly  a  more  or 
less  faulty  dietary,  associated  with  the 
depressing  influence  of  unhygienic  sur- 
roundings. It  is  a  form  of  diarrhoea  fre- 
quently met  with  in  young  infants  under 
four  months  reared  in  hospitals  or  found- 
ling institutions. 

The  onset  of  the  attack  is  gradual  and 
insidious.  A  failure  to  gain  in  weight,  or 
an  actual  loss,  may  be  the  first  symptom 
demanding  attention.  On  inquiry  the 
infant  will  be  found  to  pass  several  pale, 
pasty  evacuations  during  the  day,  which 
on  examination  will  be  found  to  consist 
in  great  measure  of  undigested  food.  In 
spite  of  ordinary  therapeutic  measures 
this  condition  is  apt  to  persist.  Some 
weeks  a  slight  improvement  may  be 
noted,  but  occasional  exacerbations  of  the 
diarrhoea  with  fever  soon  dissipate  any 
gain  that  may  have  been  made.  As  the 
disease  progresses,  the  stools  change  in 
character  and  become  more  frequent;  at 
times  they  may  be  frothy  and  sour-smell- 
ing; at  other  times  thin,  dark-colored 
and  offensive;  their  character  is  very 
variable.  The  abdomen  is  generally 
more  or  less  distended.  Cool  perspira- 
tions occur  when  the  infant  falls  asleep. 
The  urine  becomes  scanty  and  contains 


both  indican  and  urobilin.  Nutrition 
fails.  The  skin  assumes  an  earthy  hue, 
and  the  face  acquires  a  curious  look  of 
old  age.  The  infant  lies  in  its  cot  in  a 
helpless,  apathetic  state,  and  makes  its 
wants  known  by  a  scarcely  audible  whine. 
Such  infants  readily  succumb  to  some  in- 
tercurrent disease.  Any  of  the  complica- 
tions which  we  have  already  referred  to 
in  connection  with  the  preceding  groups 
may  be  met  with  in  this  condition;  the 
mortality  is  very  great.  Medicines  ap- 
pear of  no  avail.  A  complete  change  of 
air,  to  the  sea-side  or  a  bracing  country- 
or  mountain-  air,  appears  to  be  the  only 
remedial  measure  to  any  extent  effectual. 

Diagnosis. — An  exact  diagnosis  in 
these  cases  is  often  difficult.  The  ques- 
tion arises  as  to  whether  the  condition 
present  in  the  intestine  is  a  sufficient  ex- 
planation in  itself  of  the  serious  failure 
in  general  nutrition,  or  whether  we  have 
in  addition  to  deal  with  some  underlying 
constitutional  disease, — such  as  tuber- 
culosis, a  disease  which  not  infrequently 
manifests  itself  as  a  sequel  after  severe 
or  prolonged  diarrhoeal  attacks.  The 
question  will  always  be  a  difficult  one, 
but  the  physician  will  act  wisely  if  he 
base  his  opinion  rather  upon  the  history 
of  the  case  and  the  general  condition  of 
the  patient  than  upon  any  one  particu- 
lar symptom  or  physical  sign. 

Prognosis. — The  prognosis  in  cases  of 
chronic  diarrhoea  must  always  be  very 
guarded.  To  some  extent  it  is  dependent 
on  the  previous  constitution  of  the  in- 
fant, on  the  hygienic  conditions  obtain- 
able, and  upon  the  zeal  and  regularity 
with  which  all  instructions  are  carried 
out.  To  a  great  extent  it  is  also  depend- 
ent upon  the  severity  and  extent  of  the 
intestinal  lesions.  When  ulceration, 
either  catarrhal  or  follicular,  is  present 
to  any  considerable  degree,  the  prognosis 
is  always  bad,  though  perhaps,  under 


24     INFANTS,  DIARRHEAL  DISEASES.    CHRONIC  DIARRHCEA.  TREATMENT. 


favorable  conditions,  not  hopeless.  In 
those  cases,  on  the  other  hand,  where 
mere  catarrhal  or  follicular  inflammation 
without  ulceration  is  present  the  prog- 
nosis is  distinctly  better.  With  favoring 
circumstances  we  may  hope  that  a  large 
proportion  of  these  will  proceed  to  com- 
plete recovery.  To  distinguish  accurately 
between  these  two  classes  by  the  symp- 
toms or  physical  signs  existing  at  the 
time  of  examination  is  impossible.  Our 
chief  dependence  must  be  placed  on  the 
previous  history  of  the  case.  The  longer 
the  inflammation  has  lasted,  and  the 
higher  has  been  the  temperature,  the 
greater  the  probability  of  ulcerative  le- 
sions. (Holt.) 

Treatment. — With  the  conditions  pres- 
ent in  chronic  diarrhoea  no  good,  but 
often  harm,  may  result  from  the  employ- 
ment of  ordinary  astringent,  or  even 
antiseptic,  remedies  administered  by  the 
mouth.  If  drugs  are  to  be  given,  only 
those  should  be  employed  which  will  not 
disturb  the  stomach,  and  may  to  some 
extent  improve  general  nutrition.  Given 
with  this  object  in  view,  some  cases 
among  older  infants  do  undoubtedly  de- 
rive benefit  from  the  prolonged  adminis- 
tration of  iron.  It  may  be  given  either  j 
in  one  of  its  acid  preparations,  or  in  a 
neutral  and  less  irritating  salt.  Nutri- 
tion may  also  in  some  instances  be  as- 
sisted by  the  inunction  over  the  abdomen  | 
or  body  generally,  of  codliver-oil,  or 
cocoa-butter.  The  moderate  employ- 
ment of  stimulants  is  called  for  in  almost 
all  cases.  Great  attention  must  be  given 
to  the  dietary  and  to  its  proper  regula- 
tion; and  to  this  end  the  stools  should  be 
frequently  examined.  Fats  are  only  to 
be  allowed  with  much  caution.  Starchy 
foods  should  be  more  or  less  predigested. 
Considerable  benefit  may  be  derived 
from  the  employment  of  scraped  meat, 
meat-juice,  broths,  and  peptonized  meat- 


foods.  For  younger  infants  milk-foods 
will  require  very  careful  preparation; 
and  in  some  cases  may  have  to  be  alto- 
gether discontinued.  In  older  children 
they  may  be  cautiously  employed,  always 
watching  the  stools  for  signs  of  undi- 
gested material.  No  absolute  rules  can 
be  laid  down  suitable  for  all  cases;  each 
case  must  be  studied  by  itself. 

Literature  of  '96-'97-'98. 

In  the  treatment  of  infantile  diarrhoea 
an  absolute  sterilized  milk  diet  should  be 
given,  and  the  use  of  some  mild  alkaline 
water,  such  as  that  of  Vals  or  Vichy,  to 
which  may  be  added  some  white  of  egg 
to  form  albumin-water. 

Should  the  diarrhoea  be  so  active  as 
to  deplete  the  patient  to  a  dangerous  ex- 
tent hypodermoclysis  or  the  subcutane- 
ous injection  of  artificial  serum  or  even 
of  real  serum  should  be  employed. 
Lesage  (Revue  de  Therap.  Medico-Chir., 
Dec.  15,  '96). 

We  have  before  insisted  upon  the  ne- 
cessity of  placing  the  patient  under  the 
most  perfect  hygienic  conditions  pos- 
sible, and  of  securing  abundance  of  fresh 
air.  In  the  treatment  of  these  cases  our 
chief  therapeutic  reliance  must  be  upon 
the  administration  of  injections  into  the 
colon.  Weak  solutions  of  silver  nitrate, 
if  the  bowels  are  thoroughly  irrigated 
beforehand  by  simple  sterile  water,  may 
prove  of  much  service.  The  readiness 
with  which  this  drug  is  decomposed  ap- 
pears to  offer  serious  objections  to  its 
use.  Preferable  to  it,  in  our  opinion, 
will  be  found  one  of  the  salts  of  zinc 
(gr.  iv-Oj),  or  tannic  acid  (gr.  xxx-Oj), 
or  the  fluid  extract  of  hamamelis  (5i-5ii 
to  Oj),  or  the  colorless  fluid  extract  of 
hydrastis  (oi-Oj).  Any  one  of  these  may 
be  employed  as  a  high  injection  after 
thorough  irrigation  by  the  normal  saline 
solution.  Opium  should  be  made  use  of 
only  to  moderate  excessive  peristalsis, 


INFANTS,  DIARRHCEAL  DISEASES. 


CHRONIC  DIARRHOEA.    TREATMENT.  25 


and  in  these  cases  is  best  given  in  a  little 
starch-water  by  rectal  injection. 

High  rectal  injections  of  value  in  the 
chronic  diarrhoea  of  infancy  in  which 
there  is  a  glairy  mucous  discharge  due 
to  an  enteritis.  In  addition  to  ordinary 
water  some  extract  of  rhatany  and  mucil- 
age of  acacia  may  be  injected.  If  there 
is  any  doubt  as  to  the  purity  of  the 
water,  it  should  be  boiled  before  it  is 
injected.  In  other  instances  hypo- 
sulphite of  sodium  in  the  proportion  of 
2  drachms  per  pint  of  water,  to  which 
has  been  added  a  little  mucilage  of 
acacia,  may  be  given  night  and  morning 
in  this  manner,  with  advantage.  Dau- 
chez  (Revue  Mensuelle  des  Sciences  des 
l'Enfance,  May,  '96). 

The  value  of  the  administration  of 
opium  in  this  disease  is  a  subject  on 
which  there  has  been  much  difference  of 
opinion.  All  writers,  however,  agree 
that  it  should  be  avoided  at  the  outset; 
but  many  indications  for  its  employment, 
in  our  opinion,  may  arise  during  the 
latter  stages  of  the  disease. 

Literature  of  '96-'97-'98. 

Indications  and  contra-indications  for 
the  use  of  opium  in  the  diarrhoeas  of 
young  children.  It  is  contra-indicated: 
1.  In  the  first  stages  of  acute  diarrhoea, 
before  the  intestinal  canal  has  been  freed 
from  decomposing  matter.  2.  When  the 
passages  are  infrequent  and  of  bad  odor. 
3.  When  there  is  a  high  temperature  or 
cerebral  symptoms  are  present.  4.  When 
its  use  is  followed  by  elevation  of  tem- 
perature or  the  passages  become  more 
offensive.  It  is  indicated:  1.  When  the 
passages  are  large  and  watery.  3.  In 
dysenteric  diarrhoea,  together  with 
castor-oil  or  a  saline.  4.  In  late  stages, 
with  small,  frequent,  nagging  passages. 
5.  When  the  passages  consist  largely  of 
undigested  food,  and  the  bowels  act  as 
soon  as  food  is  taken  into  the  stomach. 
Crandall  (Archives  of  Ped.;  Med.  and 
Surg.  Rep.,  Sept.  25,  '97). 

Stimulants,  in  our  opinion,  are  neces- 
sary in  the  majority  of  cases;    they  I 


should  be  used  cautiously  at  first,  but 
liberally  in  the  later  stages  of  the  dis- 
ease. Good  whisky  and  brandy  are 
preferable  to  wines;  aromatic  spirit  of 
ammonia  may  occasionally  be  of  service 
in  small  frequently  repeated  doses.  Caf- 
feine may  also  be  employed  either  in  a 
single  solution  or  in  the  form  of  a  well- 
prepared  tea  or  coffee. 

In  all  instances  where  the  temperature 
runs  an  elevated  course  we  have  much 
confidence  in  the  value  of  hydrotherapy. 
This  treatment  may  be  employed  in  the 
form  of  cool  baths,  the  cold  wet  pack,  or 
cool  irrigation  of  the  intestines.  Of  the 
three  methods  our  preference  is  for  cool 
baths;  whenever  the  temperature  of  the 
body  rises  above  102°  F.  the  infant 
should  be  placed  in  a  bath  containing 
water  at  the  temperature  of  about  95°  F., 
which  temperature  should  be  quickly 
lowered  to  90°  F.  or  85°  F.  A  cloth 
wrung  out  of  cold  water  should,  at  the 
same  time,  be  kept  on  the  head.  The 
infant  should  remain  in  the  bath  from 
three  to  ten  minutes;  the  duration  vary- 
ing according  to  the  age  and  feebleness 
of  the  infant.  It  is  to  be  remembered 
that  infants  are  affected  by  a  cold  bath 
more  promptly  than  adults,  and  are  more 
easily  depressed  by  it.  Care  should  be 
taken,  therefore,  to  watch  its  effects,  and, 
if  necessary,  to  use  stimulants  after  it  is 
over. 

The  patients  should  be  bathed  daily, 
or  even  twice  daily  if  greatly  prostrated, 
with  sea-salt  water,  made  by  adding  a 
handful  of  salt  to  about  4  gallons  of 
water  at  about  80°  F.,  at  the  end  of  the 
bath  water  of  about  60°  F.  being  poured 
over  the  whole  body.  Louis  Fischer 
(Post-graduate,  Sept.,  '92). 

Great  success  in  extreme  cases  of  en- 
teritis by  the  cold  bath  at  a  temperature 
of  68°  F.  Brunon  (La  Normandie  Med., 
Aug.  1,  '93). 

A  cold  wet  pack  may  occasionally  with 
advantage  replace  the  cool  bath  where 


26       INFANTS,  DIARRHCEAL  DISEASES. 


ACUTE  ILEOCOLITIS.  SYMPTOMS. 


circumstances  are  not  convenient  for  the 
employment  of  the  latter.  Of  late  years 
the  irrigation  of  the  colon  with  cool 
water  has  been  employed  in  cases  of 
hyperpyrexia.  It  is  unquestionably  a 
more  powerful  method  than  either  bath 
or  pack,  and  when  used  with  discretion 
may  prove  of  more  value.  Its  action, 
however,  is  less  under  the  control  of  the 
physician  than  that  of  baths,  and  serious 
depression  of  the  nerve-centres  may  re- 
sult from  the  employment  of  too  cold  or 
too  long-continued  irrigation. 

Should  the  prostration  become  ex- 
treme, or  hydrencephaloid  symptoms 
make  their  appearance,  subcutaneous  in- 
jections of  a  sterilized  normal  saline  solu- 
tion, as  described  in  the  article  on 
Cholera  Infantum,  ought  to  be  em- 
ployed. In  severe  cases  three  or  four  in- 
jections a  day  of  30  cubic  centimetres 
each  should  be  given.  Not  only  do  these 
injections  stimulate  the  flagging  circu- 
lation, but  they  dilute  the  toxins  in 
the  blood  and  favor  their  elimination 
through  the  excretory  organs;  in  many 
instances  they  check  in  a  remarkable 
way  the  symptoms  of  nervous  irritation. 

Dietary. — For  the  first  twelve  or 
twenty-four  hours,  according  to  the  se- 
verity of  the  case,  only  cool  sterile  water 
should  be  permitted  to  the  infant.  After 
this  period  a  weak  sugar-of-milk  solution 
may  be  given  in  small  quantities  to  in- 
fants under  three  months;  to  those  over 
three  months  a  thin  barley-  or  rice-  water 
sweetened  with  sugar  of  milk  may  be 
allowed.  Great  caution  must  be  exer- 
cised with  all  albuminous  foods  so  long 
as  the  stools  retain  their  offensive  odor. 
White-of-egg  or  albumin-  water  forms  an 
excellent  method  of  administering  an 
easily-assimilated  proteid.  To  prepare  it 
the  white  of  an  egg  is  to  be  shaken  up  in 
a  flask  with  from  6  to  12  ounces  of  water; 
the   solution   is  then   to   be  strained 


through  muslin,  and  a  little  salt  and 
sugar  of  milk  added.  A  carefully-pre- 
pared whey  may  also  be  allowed,  and  is 
often  relished.  In  older  children  raw 
meat- juice  in  small  amount,  a  weak 
broth,  or  one  of  the  peptonized  foods 
may  be  administered  with  advantage. 
Milk  in  all  forms  should  be  forbidden 
until  the  stools  begin  to  assume  a  normal 
appearance;  its  employment  should  then 
be  resumed  only  gradually.  As  Siebert 
has  emphasized  in  a  recent  paper,  under- 
feeding of  the  infant  with  milk-sugar 
solution,  thin  gruel,  or  strained  soup  can 
do  little  harm;  while  milk  even  in  small 
quantities  can  aid  the  infection,  but  not 
the  nourishment  of  the  body. 

Hygiene. — During  the  attack  the 
infant  should,  as  far  as  possible,  be  con- 
fined to  its  cot.  Soft  unirritating  flannel 
should  be  worn  next  the  skin.  Great 
care  should  be  exercised  lest  the  buttocks 
become  irritated  by  the  discharges, 
diapers  should  be  changed  promptly  as 
soon  as  soiled,  and  the  application  of 
some  greasy  emollient  will  frequently 
prevent  the  development  of  the  ery- 
thematous and  sometimes  ulcerative  con- 
dition which  in  these  cases  is  so  liable  to 
occur.  The  infant  should  be  allowed  all 
the  fresh  air  possible.  As  soon  as  the 
violence  of  the  attack  has  passed  off,  it 
should  be  sent,  if  practicable,  either  to 
the  sea-side  or  to  a  bracing  country-  or 
mountain-  air. 

Inflammatory  Diarriice a  in  which 
in  Addition  to  the  Systemic  Infec- 
tion the  Symptoms  of  an  Acute 
Local  Inflammation  have  a  Promi- 
nent Part — Acute  Ileocolitis  (Holt). 

Symptoms. — The  symptoms  in  this 
form  of  disease  generally  commence 
abruptly,  and  for  the  first  few  days 
closely  resemble  those  of  the  preceding 
form.    The  vomiting,  however,  is  not 


INFANTS,  DIARRHCEAL  DISEASES. 


ACUTE  ILEOCOLITIS.    SYMPTOMS.  27 


generally  persistent:  the  temperature, 
although  high  at  the  onset,  soon  falls, 
and  remains  about  102°  F.,  and  the  mo- 
tions are  of  a  greenish  or  greenish-yellow 
color  and  very  frequent.  After  two  or 
three  days  the  discharges  assume  a  more 
•characteristic  appearance.  They  become 
small  in  amount,  are  of  a  grass-green  or 
brown  color;  contain  a  large  quantity  of 
mucus;  a  variable  amount  of  blood;  and 
are  passed  with  much  pain  and  straining. 
Such  stools  may  either  have  a  compara- 
tively slight  odor,  or  a  distinctly  putrid 
.and  offensive  one.  Under  the  micro- 
scope, undigested  material,  epithelial 
cells,  pus-corpuscles,  and  streptococci, 
with  other  forms  of  bacteria,  are  seen. 

The  abdomen  may  now  show  signs  of 
slight  distension;  tenderness  on  pressure 
may  be  elicited  along  the  course  of  the 
colon,  and  the  urine,  if  collected,  may 
show  the  presence  of  a  small  amount  of 
albumin.  As  the  disease  progresses  the 
severe  straining  frequently  leads  to  a  dis- 
tinct prolapse  of  the  bowel. 

If  proper  measures  have  been  em- 
ployed, the  severity  of  the  symptoms 
generally  begins  to  subside  toward  the 
end  of  the  first  week.  The  motions  now 
diminish  in  frequency:  they  no  longer 
show  signs  of  blood;  pain  and  tenesmus 
lessen,  and  the  mucus  decreases  in 
.amount.  In  many  cases,  however,  re- 
covery is  slow,  and  relapses  on  the  slight- 
est indiscretion  are  liable  to  take  place. 
Much  care  is  necessary  lest  the  inflamma- 
tory process  go  on  to  ulceration. 

The  persistence  for  two  or  three  weeks 
of  brown  mucous  stools  with  moderate 
pyrexia,  and  a  failing  nutrition  are,  ac- 
cording to  Holt,  indicative  that  ulcera- 
tion has  taken  place. 

In  the  more  recent  form  the  tempera- 
ture remains  steadily  high;  the  motions 
are  very  frequent  and  contain  much 
blood;  and  the  infant  quickly  falls  into 


a  typhoid  state  in  which  stupor,  delirium, 
or  convulsions  are  liable  to  occur.  If  the 
case  survive,  the  symptoms  may  moder- 
ate; but  prostration  is  extreme,  and  some 
pulmonary  or  cerebral  complication  is 
apt  to  turn  the  scale  on  the  wrong  side. 
Some  ulceration  is  almost  always  present 
in  these  cases,  retarding  recovery  for 
for  many  weeks.  A  long  period,  during 
which  careful  dietetic  and  medicinal 
measures  must  be  faithfully  employed, 
may  still  reappear  before  complete  res- 
toration to  health  is  secured. 

The  membranous  type  if  the  disease  is 
fortunately  of  rare  occurrence.  In  this 
form  the  symptoms  are  of  an  alarming 
character  from  the  very  outset.  Not  only 
do  the  stools  contain  much  blood  and 
mucus,  but  an  examination  of  these 
under  water  may  reveal  numerous  shreds, 
and  sometimes  large  patches  of  pseudo- 
membrane.  Pronounced  nervous  symp- 
toms, such  as  stupor  or  convulsions,  may 
at  the  onset  mark  the  symptoms  of  local 
inflammation.  These  cases  run  a  severe 
course,  typhoid  symptoms  develop  early, 
and  recovery  is  comparatively  rare. 

In  some  cases  which  for  the  first  two 
or  three  weeks  have  shown  symptoms  of 
gastro-enteric  infection  rather  than  of 
local  inflammation,  owing  either  to  the 
feeble  constitution  of  the  infant  or  to  the 
intensity  and  duration  of  the  local  irri- 
tation, a  follicular  ulceration  develops, 
and  symptoms  of  local  inflammation 
make  their  appearance.  The  motions  now 
become  small,  slimy,  and,  to  a  variable 
extent,  tinged  with  blood;  their  color  is 
most  frequently  of  a  dark  green  or 
brown,  and  their  odor  usually  offensive. 
Pain  at  this  stage,  though  present,  is  no 
longer  so  prominent  a  feature  as  during 
the  earlier  stages  of  the  disease;  pyrexia 
is  only  moderate;  the  motions  are  not 
very  frequent,  but  the  strength  of  the 
infant  gradually  fails,  and  the  general 


28       INFANTS,  DIARRHEAL  DISEASES. 


ACUTE  ILEOCOLITIS.  TREATMENT. 


emaciation  becomes  very  noticeable. 
Under  the  microscope  the  stools  are  seen 
to  contain  epithelial  cells  in  large  num- 
bers, numerous  leucocytes,  and  strepto- 
cocci associated  with  bacilli. 

The  course  of  these  cases  is  generally 
downward.  Exacerbations  and  relapses 
are  easily  excited.  Only  the  few  recover 
completely,  and  in  these  convalescence 
is  always  slow.  The  fatal  result  is  fre- 
quently hastened  by  some  intercurrent 
disease. 

Diagnosis. — Like  the  preceding,  this 
form  of  inflammatory  diarrhoea  is  to  be 
distinguished  from  intussusception.  It 
is  important  to  remember  that  with  in- 
tussusception, although  we  may  have 
vomiting,  bloody  stools,  and  tenesmus,  we 
have  no  pyrexia.  Later  on,  the  absence 
of  faecal  matter  in  what  passes  from  the 
bowel,  the  tenesmus,  the  tympanites,  the 
stercoraceous  vomiting,  and  the  slowly 
rising  temperature  complete  a  picture 
quite  different  from  that  of  an  ileocolitis. 
Typhoid  fever,  as  we  have  before  men- 
tioned, very  rarely  presents  itself  in  an 
infant. 

A  diagnosis  of  the  presence  of  ulcera- 
tion is  to  be  made  from  the  whole  char- 
acter of  the  case,  rather  than  from  any 
one  special  symptom.  Where  mucous 
stools  persist  for  several  weeks  with  only 
moderate  fever,  but  with  distinct  wasting 
and  loss  of  strength,  a  condition  of  ulcer- 
ation is  more  than  probable. 

Prognosis. — The  prognosis  must  be 
greatly  dependent  on  the  vitality  and 
strength  of  the  infant,  upon  the  hygienic 
and  dietetic  conditions  that  can  be  se- 
cured, upon  the  severity  of  the  attack, 
and  upon  the  season  of  the  year.  Deli- 
cate infants  under  unhygienic  conditions 
generally  succumb  early.  Continuous 
high  fever,  the  presence  of  a  large 
amount  of  blood  in  the  evacuations,  se- 
vere nervous  disturbances,  and  symptoms 


indicative  of  extreme  feebleness  of  the 
circulation  are  always  to  be  regarded  as- 
unfavorable. 

Treatment. — The  same  measures  are 
to  be  employed  at  the  outset  in  this  group 
of  cases  as  in  the  preceding.  Milk  and 
all  milk-foods  are  to  be  forbidden.  A 
full  dose  of  castor-oil  or  an  effective  dose 
of  calomel  is  to  be  promptly  adminis- 
tered, and  followed  within  a  few  hours 
by  copious  irrigations  of  the  colon  with 
tepid  saline  solution  (sodium  chloride,  1 
ounce;  water,  1  gallon).  The  compress 
over  the  abdomen,  which  we  have  already 
advised  as  an  excellent  sedative,  should 
also  be  applied.  After  the  second  or 
third  irrigation  of  the  intestines,  should 
painful  straining  persist,  a  small  quan- 
tity (5ii-5iv)  of  a  thin  starch  solution,  to 
which  from  1  to  3  drops  of  tincture  of 
opium,  according  to  the  age  of  the  in- 
fant, has  been  added,  should  be  gently 
thrown  into  the  rectum,  with  the  object 
of  moderating  excessive  peristalsis  and 
lessening  tenesmus.  These  opiate  injec- 
tions may  be  repeated,  if  necessary,  once 
or  twice  daily.  Should  the  stools  contain 
a  large  amount  of  blood,  rectal  injections 
of  hot  water,  106°  F.,  to  which  a  small 
amount  of  fluid  extract  of  hamamelis  has 
been  added,  may  be  administered  for  ten 
or  fifteen  minutes  at  a  time,  allowing  the 
fluid  to  escape  without  hindrance.  Tan- 
nic-acid  and  weak  nitrate-of-silver  solu- 
tions have  both  been  recommended  for 
use  in  this  acute  stage.  We  consider 
them  of  more  advantage  after  the  acute 
symptoms  have,  to  some  extent,  subsided. 

Internally,  during  the  first  few  days  of 
the  acute  stage  a  mixture  containing 
castor-oil,  in  from  3-  to  10-minim  doses, 
associated  with  ipecac,  and  small  doses 
of  an  opiate  given  at  intervals  of  two  or 
three  hours,  is  strongly  recommended  by 
many  writers,  and  has  in  our  hands  been 
of  apparent  benefit.    Later,  one  of  the 


INFLUENZA. 

insoluble  preparations  of  bismuth,  to 
which  we  have  before  referred,  should  be 
given  in  full  doses  suspended  in  a  mucil- 
age with  some  aromatic  water.  Other 
and  more  powerful  antiseptics  may  in 
some  cases  be  employed.  Stimulants  are 
required  in  the  majority  of  cases.  Old 
brandy  or  whisky  forms  one  of  the  best, 
and,  given  well  diluted  in  a  little  sweet- 
ened or  albumin-  water,  is  acceptable 
even  to  the  youngest  infants. 

All  that  we  have  said  in  the  preceding 
section  in  reference  to  cool  baths,  dietary, 
and  general  hygiene  is  equally  applicable 
in  this  class  of  cases. 

Literature  of  '96-'97-'98. 

Fifty-two  children  with  grave  diar- 
rhoeas treated  with  serum  obtained  from 
asses  after  injecting  colon  bacilli  from 
virulent  milk  or  stools.  Twenty-six  chil- 
dren had  no  marked  symptoms  after  48 
hours,  fourteen  were  improved,  twelve 
unimproved.  In  all  cases  where  the 
stools  were  green  the  color  disappeared 
after  the  injections.  The  serum  obtained 
after  treating  asses  with  the  colon  bacilli 
normally  present  in  stools  did  not  give 
these  results.  Lesage  (Rev.  de  Therap. 
Med.-Chir.,  No.  24,  '96). 

Between  sixty  and  seventy  cases  of 
"summer  diarrhoea"  treated  in  children 
ranging  in  age  from  a  few  weeks  to  three 
years.  The  cases  were  in  every  way  such 
as  are  met  with  in  the  crowded  tenements 
of  large  cities  during  the  heated  term. 
Lactic  acid  was  used  in  every  case.  The 
maximum  dose  was  1 1/i  grains,  given 
every  hour.  The  result  was  the  disap- 
pearance of  all  symptoms  in  from 
twenty-four  to  forty-eight  hours.  The 
only  medicine  given  besides  the  lactic 
acid  was  an  initial  dose  of  calomel  in 
cases  where  it  was  indicated.  Bowles 
(Indian  Lancet,  Apr.  1,  '97). 

Endoxin,  which  contains  52.9  per  cent, 
of  iodine  and  14.5  per  cent,  of  bismuth, 
recommended  in  the  treatment  of  in- 
fantile diarrhoea.  The  remedy  is  harm- 
less, and  can  be  administered  in  doses  of 
1  grain  every  hour  to  a  child  a  year  old. 


SYMPTOMS.  29 

M.  Elerzarian  (N.  Y.  Med.  Jour.,  No. 
1029,  p.  270,  '98). 

A.  D.  Blackader, 

Montreal. 

INFANTS,  FEEDING  OF.  See  Nurs- 
ing and  Infant-feeding. 

INFANTS,  SCORBUTUS  OF.  See 

Scorbutus,  Infantile. 

INFLUENZA. — From  the  Italian,  in- 
fluential a  mysterious  influence. 

Definition. — Influenza,  "la  grippe,"  or 
epidemic  catarrh,  is  an  acute  febrile 
affection  generally  accompanied  by 
severe  nervous  and  catarrhal  symptoms, 
and  often  extending  rapidly  over  many 
countries  and  attacking  large  numbers 
simultaneously,  but  resulting  in  a  low 
ratio  of  mortality. 

Symptoms. — Epidemic  influenza  is  re- 
markable for  the  suddenness  of  its  at- 
tacks and  the  number  of  persons  affected 
at  the  same  time.  There  is  no  well- 
defined  period  of  incubation,  and  gener- 
ally no  prodromic  stage.  Persons  appar- 
ently in  good  health  and  engaged  in  their 
ordinary  occupations  are  suddenly  at- 
tacked with  sensations  of  coldness,  often 
increasing  to  a  chill,  with  general  de- 
pression and  severe  pains  in  the  head, 
back,  and  limbs.  The  surface  looks  pale, 
the  pulse  and  respiration  variable,  but 
these  symptoms  soon  give  place  to  dis- 
tinct febrile  reaction,  some  flushing  of 
the  face,  general  feeling  of  soreness  of 
the  muscles,  and  increased  intensity  of 
pains  everywhere,  with  great  sense  of 
weakness. 

The  pulse  and  respirations  increase  in 
frequency,  and  the  temperature  generally 
ranges  from  38°  to  40°  C.  The  skin  is 
dry,  the  urine  is  scanty  and  high  colored; 
there  is  constipation,  no  appetite,  but 
some  thirst.   In  a  large  majority  of  cases 


30  INFLUENZA. 

before  the  end  of  the  first  twenty-four 
hours  the  vessels  of  the  conjunctivae  be- 
come red,  accompanied  by  active  conges- 
tion of  the  lining  membrane  of  the  nos- 
trils, pharynx,  and  bronchial  tubes,  with 
cough  and  oppression  in  the  chest.  At 
first  the  cough  is  dry  and  harsh,  causing 
some  pain  in  the  chest,  and,  in  some  cases, 
severe  pain  in  the  region  of  the  frontal 
and  maxillary  sinuses.  During  the  sec- 
ond day  the  congested  membranes  begin 
to  secrete  a  thin,  almost  water-colored 
mucus  that  flows  from  the  nostrils  and 
renders  the  cough  less  dry,  and  on  the 
third  and  fourth  days  the  nasal  discharge 
and  the  expectoration  become  more 
opaque  or  muco-purulent,  causing  more 
or  less  moist  rhonchi  in  the  chest.  At  the 
same  time  the  pains  in  the  head,  back, 
and  limbs  and  oppression  in  the  chest 
become  less  severe,  expectoration  more 
free,  temperature  lower,  especially  dur- 
ing the  morning  hours,  and  by  the  end 
of  the  week  the  skin  becomes  bathed  in 
perspiration,  the  kidneys  secrete  more 
urine,  and  convalescence  begins. 

In  mild  cases  the  patient  usually 
quickly  recovers  his  health  and  strength, 
but  in  those  of  greater  severity,  though 
the  general  febrile  symptoms  disappear 
at  the  end  of  the  first  week,  the  inflam- 
mation of  the  mucous  membrane  of 
the  air-passages  continues,  perpetuating 
copious  muco-purulent  discharges  from 
the  nostrils,  with  some  cough  and  expec- 
toration, and  the  patient  remains  debili- 
tated several  weeks  or  even  months. 

Literature  of  '96-'97-'98. 

In  influenza  of  childhood  there  is  a 
period  of  depression  with  some  nasal  ca- 
tarrh, and  slight  dry  cough  preceding 
the  onset  of  the  fever.  It  may  last  eight 
or  ten  days.  The  onset  of  the  pyrexia  j 
is  marked  by  shivering,  the  voice  becomes  l 
hoarse,  deglutition  is  sometimes  painful, 
the  nasal  catarrh  increases,  and  there  is  I 


SYMPTOMS. 

some  dyspnoea.  Constipation  is  the  rule, 
and  in  many  cases  there  is  severe  head- 
ache, though,  in  infants,  this  may  be  re- 
placed by  convulsions.  Furst  (Scalpel, 
No.  16,  '97). 

Seven  cases  of  influenza  in  adults,  dis- 
tinguished by  extremely-copious  sweats 
and  a  marked  tendency  to  the  formation 
of  adipose  tissue.  The  cases  commenced 
with  bronchial  disturbances;  some  were 
accompanied  by  distressing  cardiac  palpi- 
tations, all  with  constipation,  lack  of 
appetite  and  scantiness  of  urine.  The 
sweats  continued  for  months  and  left  a 
neurasthenic  condition,  which  in  some 
cases  persisted  for  years.  The  sweats 
and  bronchial  disturbances  alternated, 
one  diminishing  as  the  other  increased, 
and  vice  versa.  Marquie  (Jour,  de  Med 
de  Bordeaux,  Apr.  16,  '98). 

In  severe  cases,  when  at  the  climax  of 
the  active  stage,  the  inflammation  often 
extends  through  the  bronchial  tubes  to 
the  air-cells  and  connective  tissues  of  the 
lungs,  thereby  developing  all  the  symp- 
toms of  broncho-pneumonia  as  a  compli- 
cation of  the  original  disease. 

The  relation  of  influenza  to  pneumonia 
is  that  of  a  predisposing  factor  only. 
Prudden  (Med.  Rec,  Feb.  15,  '90). 

The  course  of  pneumonia  complicating 
influenza  is  seldom  that  of  the  typical 
disease;  it  rarely  sets  in  with  a  decided 
rigor,  and  the  inflammatory  symptoms, 
notably  the  pain  in  the  side,  are  but 
little  marked.  The  local  processes  are 
not  characteristic.  Local  signs  are  not 
detectable  before  the  third  or  fourth  day. 
Crepitation  will  be  heard  over  a  consider- 
able area,  soon  disappearing  and  becom- 
ing evident  at  another.  Not  often  does 
the  process  reach  hepatization  with  defi- 
nite dullness.  Typical  rusty  sputum 
seldom  observed.  Crises  are  rare.  The 
course  of  inflammation  is  milder,  dysp- 
noea and  rapid  infiltration  being  want- 
ing. Leyden  (Berl.  klin.  Woch.,  No.  10, 
'90). 

Malignancy  found  characteristic  of  the 
pneumonia  complicating  influenza,  seven 
of  fourteen  cases  terminating  fatally. 
Sokolowski  (Internat.  klin.  Rund.,  Apr. 
13,  '90). 


INFLUENZA.  SYMPTOMS. 


Pneumonia  of  influenza  considered  as 
a  broncho-pneumonia.  It  presents  the 
following  distinctive  features:  1.  Evi- 
dence of  a  preceding  attack  of  influenza 
is  generally  present.  2.  Percussion-dull- 
ness  may  be  absent  or  only  present  for  a  j 
short  time,  shifting  its  position;  bron- 
chial breathing  may  be  the  only  physical 
sign;  moist  sounds  are  most  constantly 
present.  3.  The  sputum  is  never  typic- 
ally rusty.  4.  The  fever  usually  sets  in 
without  shivering,  and  the  temperature 
rises  gradually.  5.  The  course  is  less 
acute,  the  infiltration  disappears  slowly, 
and  convalescence  is  retarded.  Albu 
(Deutsche  med.  Woch.,  Feb.  15,  '94). 

Case  of  influenza-pneumonia  followed 
by  unmistakable  signs  of  abscess  of  the 
lung,  in  which  Pfeiffer's  bacillus  was  the 
only  organism  found  in  the  sputum. 
Hitzig  (Munch,  med.  Woch.,  No.  35,  '95). 

Three  cases  of  influenza-pneumonia 
which  progressed  to  gangrene.  Rhyner 
(Munch,  med.  Woch.,  Nos.  9,  10,  '95). 

Peculiarities  of  broncho-pneumonias  of 
influenza  in  children:    (1)  slight  eleva-  I 
tions  of  temperature  seem  to  point  to  pa- 
ralysis of  thermogenic  centres;   (2)  early  i 
tendency  to  bronchoplegia  and  pulmo-  I 
nary  collapse  due  to  depression  of  vital 
powers;    (3)  extraordinary  slowness  of  i 
course  of  disease.    Ferreira  (Revue  Men.  j 
des  Mai.  de  l'Enfance,  Mar.,  '95). 

Literature  of  '96-'97-'98. 

Influenza-pneumonia  is  characteristic- 
ally lobular,  the  inflammatory  process 
spreading  from  the  bronchi  to  the  alveo- 
lar passages  and  alveoli,  the  latter  being 
densely  and  almost  exclusively  filled  with 
leucocytes.  In  the  bronchi  their  number 
is  so  great  that  they  not  only  penetrate 
between  the  epithelial  cells,  but  cause 
partial  detachment  of  the  epithelial  lin- 
ing. The  absence  of  fibrin  is  noteworthy, 
and  is  one  of  the  reasons  why  the  infil- 
tration has,  to  the  naked  eye,  a  smooth 
appearance. 

As  a  terminal  stage  of  influenza  pul- 
monary gangrene  occurred  in  7.5  per 
cent,  of  the  writer's  cases  of  influenza- 
pneumonia.  Arteriosclerosis  may  follow 
influenza.  A.  Fraenkel  (Berl.  klin.Woch., 
Apr.  12,  '97). 

The  influenza  bacillus  is  capable  of  giv- 


ing rise  to  fibrous  or  serous,  or  even 
hemorrhagic,  exudate  in  the  lungs,  which 
may  become  purulent.  When  the  sinuses 
communicating  with  the  nose  are  in- 
flamed it  is  nearly  always  a  result  of  in- 
fection with  the  influenza  bacillus.  Lin- 
denthal  (Wiener  klin.  Woch.,  Apr.  15, 
'97). 


If  patient  with  influenza  have  also- 
croupous  pneumonia,  the  association  is- 
accidental.  The  invasion  of  the  one  but 
prepares  the  way  for  that  of  the  other. 
Nothnagel  (Internat.  klin.  Rund.,  Jan. 
12,  '90). 

Respiratory  complications  rare  and  be- 
nign in  children.  Of  218  cases,  bron- 
chitis, usually  of  a  mild  character,  was 
present  in  18.  Complications  involving 
organs  of  special  sense  were  relatively 
frequent.  Comby  (Revue  Mensuelle  des 
Malades  de  l'Enfance,  Apr.,  '90). 

In  some  of  the  wide-spreading  epi- 
demics of  influenza,  more  '  especially 
those  commencing  during  the  summer 
and  autumn  months,  there  have  been  less 
symptoms  of  inflammation  of  the  res- 
piratory mucous  membranes,  and  more 
in  the  membranous  lining,  the  stomach, 
and  viscera  of  the  abdomen.  Such  was 
the  case  in  very  many  of  the  attacks  dur- 
ing the  epidemic  commencing  in  the 
autumn  of  1889  and  recurring  to  some 
extent  almost  every  year  since.  There 
was  the  same  suddenness  of  the  attacks, 
and  the  same  severe  pains,  not  only  in 
the  head,  back,  and  limbs,  but  in  the 
epigastrium,  with  tenderness  to  pressure 
in  different  parts  of  the  abdomen,  nausea, 
and  occasional  vomiting  and  a  disturbed 
condition  of  the  bowels.    The  evacua- 


Such  a  complication  has  been  much 
more  frequently  manifested  in  childhood 
and  old  age  than  in  the  middle  period  of 
life.  And  it  is  one  of  the  chief  causes 
of  the  mortality  attributed  to  influenza. 
Croupous  pneumonia  and  pleurisy  some- 
times, though  rarely,  occur  as  complica- 
tions in  this  disease. 


32 


INFLUENZA.  SYMPTOMS. 


tions  both  from  the  stomach  and  bowels, 
though  not  frequent,  were  generally 
mixed  with  mucus  sufficient  to  show  a 
catarrhal  grade  of  general  fever  present, 
and  sometimes  led  the  practitioner  to 
suspect  that  his  patient  was  affected  with 
typhoid  fever  during  the  first  few  days 
of  his  attendance. 

In  a  few  cases  the  abdominal  symp- 
toms centered  more  in  the  region  of  the 
duodenum  and  hepatic  ducts.  This  was 
indicated  by  constant  nausea,  occasional 
vomiting,  scanty  and  high-colored  urine, 
}^ellow  or  jaundiced  hue  of  the  conjunc- 
tiva and  skin,  with  much  epigastric  dis- 
tress and  general  weakness. 

Literature  of  '96-'97-'98. 

Variety  of  influenza  characterized  by 
bilious  vomiting  described.  The  onset  is 
sudden;  occasionally  there  is  a  chill. 
Bilious  vomiting  occurs  early  and  is 
abundant  and  sometimes  obstinate. 
There  may  be  anorexia,  flatulence, 
marked  abdominal  swelling,  pains  local- 
ized in  the  right  iliac  fossa,  constipation, 
headache,  and  more  or  less  profuse  night- 
sweats.  Jasiewicz  (Jour,  de  Med.  de 
Paris,  June  6,  '97). 

In  another  class  of  cases  the  predomi- 
nant symptoms  are  limited  to  the  nerv- 
ous structures  of  the  body,  and  consist 
in  not  only  violent  pains  and  moderate 
general  fever,  but  a  general  hyperes- 
thesia throughout  the  cutaneous  and 
muscular  structures  of  the  body.  Mus- 
cular movements,  both  voluntary  and  in- 
voluntary, are  painful.  These  give  rise 
to  a  distressed  feeling  of  constriction 
around  the  chest  and  soreness,  with  much 
pain  in  different  parts  of  the  line  of  at- 
tachment of  the  diaphragm,  the  pectoral 
muscles,  and  in  the  region  of  the  heart. 
Both  cardiac  and  respiratory  movements 
are  variable  or  irregular,  a  feature  adding 
much  to  the  general  sense  of  prostration. 
In  a  few  instances  it  has  caused  feelings  I 


so  closely  resembling  those  in  angina 
pectoris  as  to  greatly  alarm  the  patients. 

The  exceptionally  severe  pains  about 
the  chest  and  pains  in  different  parts  of 
the  body  in  influenza  might  well  be  con- 
sidered partly  due  to  general  neuritis  or 
perineuritis  of  varying  degrees  of  in- 
tensity. Pepper  (Med.  News,  July  5, 
'90). 

Literature  of  '96-'97-'98. 

Attention  drawn  to  influenzal  angina, 
which  bears  a  marked  resemblance  to 
angina  pectoris,  with  which,  indeed,  it 
is  probably  identical,  being  produced 
under  the  same  conditions,  and  accom- 
panied by  the  same  symptoms. 

The  duration  of  these  sensations  is 
variable,  for  the  most  part  lasting  some 
time.  The  variability  of  these  cardiac 
affections  depends  on  whether  the  vagi, 
the  sympathetic,  or  intracardiac  ganglia 
are  affected,  or  they  may  even  depend 
on  a  bulbar  origin.  Batz  (These  de  Bor- 
deaux, '96). 

In  this  class  of  cases  especially,  and 
to  some  extent  in  all  severe  cases  of  each 
cavity,  the  functions  of  the  cardiac,  vaso- 
motor, and  respiratory  nerves  remain  im- 
paired for  a  long  time  after  general  con- 
valescence is  established.  Consequently 
the  patients  do  not  regain  ability  to  take 
active  physical  exercise  without  short- 
ness of  breath,  palpitation,  and  a  sense 
of  great  weariness  for  months — and,  in 
some,  years — after  the  original  attack. 
All  the  varieties  of  influenza  have,  in  rare 
instances,  been  complicated  with  inflam- 
mations of  the  brain  or  its  membrane,  of 
the  endocardial  structures,  the  urinary 
organs,  and  even  the  uterus. 

Meningitis  may  arise  directly  as  a  re- 
sult of  the  general  infection,  in  which 
case  it  occurs  during  the  progress  of  the 
disease;  or,  secondarily,  to  otitis,  in 
which  case  it  occurs  after  the  influenza 
has  disappeared.  The  myelitis  of  influ- 
enza may  be  diffuse  or  systemic.  The 
most  frequent  variety  of  the  former  has 
been  transverse  dorsal  myelitis. 


INFLUENZA. 

The  complications  of  the  peripheral 
nervous  system  are  the  most  common, 
and,  among  these,  neuralgia  takes  first 
rank.  Trigeminal  neuralgias  are  most 
frequent.  Disorders  of  motility  are  much 
less  common  than  those  of  sensibility. 
Influenza  may  reawaken  neuroses  from 
which  the  patient  has  long  been  free, 
exaggerate  existing  or  even  provoke  the 
explosion  of  neuroses  in  those  who  have 
never  been  affected.  These  nervous  com- 
plications distinguish  influenza  from 
dengue.  De  Brun  (La  M6d.  Moderne, 
Nov.  13,  '90). 

Renal  congestion  and  inflammation  of 
frequent  recurrence  in  the  course  of  in- 
fluenza; diagnosis .  greatly  facilitated  by 
the  use  of  the  centrifuge.  These  condi- 
tions appear  at  the  same  time  as  those 
that  occur  in  the  course  of  diphtheria 
and  typhoid  fever,  and  are  in  each  in- 
stance probably  due  to  the  toxins  of  the 
respective  diseases.  Microscopically  the 
urine  under  these  circumstances  contains 
a  small  amount  of  blood,  with  hyaline 
casts  strewn  with  granular  matter  and 
epithelial  cells,  and  also  granular  casts 
of  the  thin  variety.  In  the  nephritis  of 
scarlatina,  on  the  contrary,  the  casts  are 
of  the  wider  variety.  In  the  majority  of 
case  recovery  ensues  in  from  two  or  three 
weeks  to  two  or  three  months.  Some, 
however,  pursue  a  chronic  course.  A. 
Jacobi  (Med.  News,  June  8,  '95). 

Renal  lesions  are  not  infrequent  fol- 
lowing influenza.  Besides  transient  al- 
buminuria ha*s  been  observed  acute 
degeneration  of  the  kidney,  acute  in- 
flammation, both  forms  of  chronic  diffuse 
nephritis,  acute  hsemorrhagic  nephritis, 
and  persistent  albuminuria  not  belonging 
to  any  of  these  groups.  The  number  of 
applicants  rejected  for  life-insurance  has 
perceptibly  increased  since  the  advent  of 
influenza  in  epidemic  prevalence.  G. 
Baumgarten  (Med.  News,  June  8,  '95). 

Several  cases  of  albuminuria  in  pa- 
tients free  from  renal  trouble  before  in- 
fluenza. So-called  healthy  albuminuria 
becomes  more  serious  after  influenza,  and 
casts  appear  in  the  urine.  James  Tyson 
(Univ.  Med.  Jour.,  July,  '95). 

The  poison  acts  very  often  on  kidneys. 
In  the  simplest  cases  of  influenza  there  is 
sometimes  severe  inflammation  of  glom- 


SYMPTOMS.  33 

eruli,  with  slight  albuminuria,  which 
lasts  for  several  days,  then  disappears. 
In  other  cases  it  produces  serious  ne- 
phritis, which  from  the  start  exposes  the 
patients  to  renal  insufficiency  and  death 
from  uraemia.  Lamarque  (L'Union  Med., 
Sept.  28,  '95). 

Case  of  hsemorrhagic  nephritis  noted 
consecutive  to  grippe,  in  a  woman  32 
years  of  age,  the  haematuria  lasting 
three  weeks.  Thorough  recovery  ensued. 
Bock  (Deutsche  med.-Zeit.,  Apr.  2,  '94). 

Case  of  influenza  in  which  haemor- 
rhages occurred  with  suppression  of 
urine,  and  later  an  enormous  amount  of 
albumin.  Anaemia  supervened,  followed 
by  neuritis  and  death.  F.  C.  Shattuck 
(Univ.  Med.  Jour.,  July,  '95). 

Case  of  cystitis,  caused  by  influenza, 
characterized  by  pain  in  the  lower  part 
of  the  abdomen;  painful  micturition, 
haematuria  at  the  end  of  the  act  on  eighth 
day  of  the  disease.  Yielded  readily  to 
treatment.  Comby  (Med.  Bull.,  May, 
'95). 

One  writer  states  that,  in  27  cases  of 
the  disease  occurring  in  pregnant  women 
under  his  observation,  abortion  or  mis- 
carriage took  place  in  17. 

Series  of  159  cases  of  influenza  ob- 
served, 138  in  the  non-gravid  and  21  in 
the  pregnant  condition.  Of  the  latter, 
pregnancy  was  interrupted  in  17  cases, 
and  in  4  continued  its  course.  The  138 
non-gravid  cases  showed  in  all,  with  the 
exception  of  3,  alterations  in  the  gener- 
ative functions — partly  by  menorrhagia, 
partly  by  metrorrhagia,  partly  by  ex- 
acerbations of  already-existing  sexual 
pains.  Hsemorrhagic  form  of  endome- 
tritis set  in  which  led,  in  the  pregnant 
state,  to  abortion  or  interruption  of  the 
pregnancy.  Rudolf  Miiller  (Miinch.  med. 
Woch.,  Oct.  8,  '95). 

Literature  of  '96-'97-'98. 

Of  the  four  clinical  forms — the  purely 
febrile,  the  nervous,  the  catarrhal,  and 
the  gastric — women  suffer  most  from  the 
first  two.  Symptoms  connected  with  the 
genital  organs  are  very  common,  and 
menorrhagia  and  intermenstrual  dis- 
charge are  frequent.     Pre-existent  dis- 


34  INFLUENZA. 

eases,  such  as  endometritis,  congestive  or 
infectious,  show  exacerbations. 

In  a  school,  chlorotic  and  anaemic  girls 
in  whom  menstruation  was  irregular,  the 
flow  became  and  continued  regular  after 
an  attack  of  influenza. 

Pregnancy  and  labor  were  commonly 
gravely  affected,  and  many  abortions  and 
premature  labors  occurred  during  the 
several  epidemics.  Labor-pains  were 
weak  and  specially  painful,  and  the  con- 
finement was  prolonged.  Gabriel  v. 
Engel  (Wiener  med.  Presse,  Nos.  43,  44, 
'96). 

Attention  called  to  the  fact  that,  dur- 
ing the  1890  influenza  epidemic,  the 
number  of  births  in  Hungary  was  41,- 
866  less  than  during  previous  years,  and 
during  the  following  three  years;  during 
September  and  October  alone  in  1890, 
there  were  19,768  less  children  born  than 
in  the  same  months  of  other  years. 
Engel  (Centralb.  f.  Gyniik.,  No.  24,  '97). 

Observations  upon  50  women  who  had 
grippe  during  pregnancy  or  the  puerperal 
state. 

In  pregnancy  grippe  affected  the  nerv- 
ous system  profoundly  in  1  case,  the 
gastro-intestinal  tract  in  2  others,  while 
in  the  majority  the  respiratory  organs 
were  attacked.  In  1  of  the  intestinal 
cases,  pyelitis  developed.  The  majority 
of  pregnant  women  in  whom  grippe 
affected  the  respiratory  organs  recovered 
without  especial  difficulty.  A  small  num- 
ber had  pneumonia,  which  proved  a  seri- 
ous complication.  In  1  patient  otitis  and 
meningitis  developed,  both  caused  by  the 
pneumococcus.  The  sputum  of  these 
showed  abundant  pneumococci. 

So  far  as  the  influence  of  grippe  on  the 
continuation  of  pregnancy  was  observed, 
but  a  very  few  cases  had  metrorrhagia. 
Labor  itself  was  not  especially  influenced 
by  grippe.  Bar  and  Boulle  (Amer.  Jour. 
Med.  Sci.,  Dec,  '98). 

One  of  the  most  constant  and  impor- 
tant influences  accompanying  epidemics 
of  influenza  is  a  marked  impairment  of 
vitality  or  vital  resistance,  as  shown  in 
continued  loss  of  strength  and  endur-  i 
ance,  mental  despondency,  and  increased 
attacks  of  bronchitis,  pneumonia,  and 


SYMPTOMS. 

tuberculosis,  not  only  during  its  active 
prevalence,  but  for  many  months  there- 
after. 

Ten  cases  of  psychoses  following  influ- 
enza seen  at  the  clinic  at  Bonn.  The 
mental  disorder  set  in  during  convales- 
cence, and  was  preceded  by  a  sense  of 
fatigue  and  obstinate  insomnia.  It  was 
initiated  by  acute  delirium,  which  in  all 
cases  but  two  passed  into  melancholia  of 
variable  duration.  The  prognosis  is 
favorable.  More  than  half  of  the  10  cases 
possessed  a  neuropathic  heredity,  and  2 
"nervous  irritability."  Convalescence 
should  be  carefully  watched  and  signs 
of  mental  aberration  combated  with 
stimulants  and  restoratives.  Mispelbaum 
(Zeitschrift  f.  Psychiatrie  und  Gericht- 
liche  Med.,  B.  47,  H.  1,  '90). 

Influenza  may  be  the  sole  etiological 
element  in  the  development  of  a  psycho- 
sis, or  it  may  merely  act  as  an  exciting 
factor  in  disturbing  the  equilibrium  of  a 
nervous  system  already  deranged  or  in 
intensifying  a  latent  mental  disorder. 
Kern  (Munch,  med.  Woch.,  Apr.  29,  '90). 

Influenza  is  responsible  for  none  of  the 
cases  of  true  psychoses,  inasmuch  as  in 
104  cases  only  21  were  found  in  which 
neither  hereditary  tendencies  nor  alco- 
holism nor  neurotic  temperament  was 
absent.  Jolly  (Deutsche  med.  Woch., 
Mar.,  '91). 

Fifty-four  cases  of  insanity  following 
influenza.  About  one-fourth  may  be 
classed  among  the  cases  of  febrile  de- 
lirium. They  begin  as  acute  hallucina- 
tory confusion,  contemporaneous  with 
the  fever,  and  disappear  several  weeks 
after  the  latter  has  subsided.  The  post- 
febrile cases  may  be  divided  into  three 
classes.  1.  Asthenic  psychoses  with  hal- 
lucinations and  delusions,  sometimes  ex- 
altative,  at  others  depressive.  2.  Melan- 
cholias, from  simple  neurasthenic  or 
hypochondriac  disturbance  to  profound 
stuporosc  conditions.  3.  The  manias. 
The  prognosis  is  good.  Kirn  (Allgemeine 
Zeitsch.  f.  Psy.  u.  Psy.-gerichtliche  Med., 
B.  48,  '92). 

The  nervous  and  mental  consequences 
of  influenza  in  the  majority  of  oases  are 
poisoning  by  some  ptomaine  produced  by 
the  bacteria  of  the  disease.    P.  C.  Knapp 


INFLUENZA.  SYMPTOMS. 


35 


(Boston  Med.  and  Surg.  Jour.,  Sept.  15, 
'92). 

Influenza  can  only  be  directly  followed 
by  tuberculosis  when  a  pre-existing 
tubercular  infection  was  present.  Du- 
brandy  (La  Semaine  Med.,  July  29,  '91). 

Case  of  bilateral  neuritis  of  the  bra- 
chial plexus  suddenly  followed  influenza. 
Complete  paralysis  of  the  arms  occurred, 
with  atrophy  and  reaction  of  degenera- 
tion in  the  paralyzed  muscles.  The 
father  of  the  patient  had  been  similarly 
affected  in  the  lower  members  also  after 
influenza.  M.  A.  Claus  (Jour,  de  Med., 
de  Chir.,  et  de  Pharm.,  May  26,  '94). 

Neuritis  of  the  optic  nerve  due  to  la 
grippe  is  of  relatively  rare  occurrence; 
it  may  affect  one  or  both  eyes,  and  may 
produce  partial  transient  impairment  of 
vision,  partial  permanent  impairment  of  J 
vision,  or  absolute  permanent  blindness. 
Failure  of  vision  begins  from  three  to 
fourteen  days  after  the  commencement 
of  the  attack  of  la  grippe,  and  proceeds 
rather  rapidly.  It  is  always  preceded  by 
intense  frontal  or  circumorbital  cephal- 
algia. Treatment  has  but  little  effect  to 
promote  a  cure.  If  recovery  follows,  it 
takes  place  spontaneously  and  accom- 
panies improvement  in  the  patient's 
general  condition.  Weeks  (N.  Y.  Med. 
Jour.,  Aug.  8,  '91). 

From  the  study  of  twenty-seven  re- 
ported, cases  of  papillary  and  retrobulbar 
neuritis,  following  influenza,  the  follow- 
ing conclusions  are  drawn:  1.  The  virus 
of  influenza  may  attack  the  optic  nerve 
in  its  papillary  or  in  its  retrobulbar  por- 
tion. 2.  The  ocular  lesions  of  influenza 
may  be  divided  into  those  produced  by 
infection  from  the  exterior  and  those 
caused  by  metastasis.  3.  The  papillitis, 
due  to  influenza,  appears  in  from  three 
to  fourteen  days  after  the  commence- 
ment of  the  disease.  4.  Retrobulbar  neu- 
ritis is  more  common  than  papillitis  or 
neuroretinitis.  It  differs  from  the  neu-  | 
ritis  due  to  alcohol,  tobacco,  or  lead,  in 
that  it  presents  an  acute  or  a  subacute 
form,  marked  by  a  rapid  and  progressive 
diminution  of  vision.  Prognosis  should 
be  guarded,  improvement  being  slow, 
sometimes,  though  exceptionally,  being 
complete.  During  the  acute  stage 
leeches  to  the  temples,  absolute  rest,  in-  i 


jections  of  pilocarpine,  quinine,  and  salic- 
ylates internally  should  be  employed. 
In  the  later  stages  iodide  of  potassium, 
the  continuous  current,  injections  of 
strychnine  into  the  temples,  and  mer- 
cury are  indicated.  Antonelli  (Recueil 
d'Ophtal.,  June,  '92). 

Influenza  is  a  specific  nervous  fever 
and,  like  cerebro-spinal  fever,  is  infec- 
tious. Backache,  spinal;  headache,  de- 
lirium, tinnitus,  etc.,  due  to  implication 
of  cranial  nerves;  vomiting  and  diarrhoea 
probably  reflex;  complications  mainly 
nervous.  H.  Waite  (Brit.  Med.  Jour., 
June  22,  '95). 

Case  in  which  several  weeks  after  in- 
fluenza, when  weather  extremely  severe, 
patient  noticed  paralysis  of  muscles  sup- 
plied by  facial  nerve,  first  left  side  then 
right.  Brother  and  father  had  had  facial 
palsy.  W.  J.  Barkas  (Lancet,  Jan.  26, 
'95). 

Case  of  transitory  aphasia  following  in- 
fluenza. Dargelo  (Nouveau  Montpellier 
Med.,  July  20,  '95). 

Aphasia  observed  in  the  course  of  in- 
fluenzal pneumonia.  Pailhas  (Arch,  de 
Neurol.,  May,  '95). 

Two  cases  of  cerebral  sclerosis  follow- 
ing influenza.  Rendu  (Le  Prog.  Med., 
Jan.  5,  '95). 

Literature  of  '96-'97-'98. 

Man,  aged  40,  a  tailor,  alcoholic  and 
very  neurotic,  had  been  under  personal 
observation  during  the  last  and  the  pres- 
ent year,  suffering  from  a  recurrent  des- 
quamative affection  of  the  skin  following 
influenza. 

In  February,  1895,  he  had  a  typical 
severe  attack  of  influenza,  and  was  in 
bed  a  month  with  it.  He  does  not  think 
he  had  any  rash.  In  the  beginning  of 
March  his  hands  and  feet  began  to  peel 
and  his  nails  to  become  dry  and  brittle. 
He  came  under  observation  on  March 
21st,  when  the  following  note  was  made: 
"Over  both  hands  the  epidermis  is  peel- 
ing off  in  large  sheets,  especially  from 
the  fingers,  leaving  the  subjacent  skin 
healthy.  There  is  hypertrophy  of  the 
nail-bed  of  all  the  fingers,  and  especially 
of  the  thumbs,  where  the  piling  up  of 
epidermis  is  so  great  as  to  threaten  the 
vitality  of  the  nail.    There  is  a  similar 


INFLUENZA.  SYMPTOMS. 


desquamation  of  the  soles  and  similar 
changes  in  the  toe-nails,  but  less  marked. 
The  man  is  in  a  marked  condition  of  post- 
influenzal neurasthenia.' 

Subsequently  all  his  nails  fell  off,  and 
were  replaced  by  new  nails  with  promi- 
nent transverse  ridges.  His  nervous  pros- 
tration persisted;  he  complained  of  per- 
sistent "paralytic  feelings"  in  the  fingers, 
and  disordered  sensation.  Finally  he  be- 
came profoundly  melancholic,  but  im- 
proved greatly  at  a  convalescent  home  at 
the  sea-side. 

He  had  another  attack  of  influenza  in 
October,  1895,  followed  by  similar 
changes  and  total  loss  of  nails,  and  again 
in  February,  1896.  Recently  he  had  a 
fresh  attack,  called  "bronchitis,"  and  he 
returned  to  the  hospital  on  November 
4th  with  desquamation  of  all  the  fingers, 
although  more  marked  in  some  than  in 
others.  There  is,  on  examination,  no 
anaesthesia,  but  some  loss  of  tactile  sensi- 
bility. J.  J.  Pringle  (Brit.  Jour,  of 
Derm.,  Dec,  '96). 

The  great  majority  of  cases  of  multiple 
neuritis  following  influenza  are,  in 
reality,  instances  of  peripheral  neuritis, 
an  intoxication  of  the  nerve- trunks ;  this 
may  be  sufficient  to  produce  rapid  de- 
struction of  the  nerve-fibres  or  just 
enough  to  cause  pain  by  irritation.  This 
is  sustained  by  the  fact  that  the  salicy- 
lates are  useful  in  these  cases,  owing  to 
their  power  of  promoting  the  elimination 
of  some  toxic  agents.  H.  B.  Allyn  (Jour. 
Amer.  Med.  Assoc.,  July  24,  '97). 

In  some  cases  presenting  otalgia  the 
subjects  had  moderate  fever,  but  the 
aural  pain  was  intense,  and  lasted  from 
three  to  nine  days.  No  evidence  of  an 
inflammatory  process  could  be  observed 
on  examining  the  ears.  These  cases  be- 
lieved to  be  examples  of  pure  otalgia, 
constituting  an  abortive  form  of  epidemic 
influenza.  D.  Kaufmann  (N.  Y.  Med. 
Jour.,  Feb.  13,  '97). 

The  most  common  of  nervous  sequelae 
is  neurasthenia.  The  neurasthenia  fol- 
lowing influenza  differs  but  little  from 
the  various  recognized  types  of  this  affec- 
tion. We  meet  with  the  eerebro-spinal, 
the  spinal,  and  the  sympathetic  type.  A 
noteworthy  feature  of  the  cerebro-spinal 
type  is  the  great  depression,  amounting 


to  melancholia,  with  suicidal  tendencies; 
so  that  the  term  neurasthenia  no  longer 
applies  to  this  affection. 

The  spinal  form  of  neurasthenia  is  a 
less  common  sequel  of  influenza.  In  a 
few  cases  observed  it  was  accompanied 
by  marked  symptoms  of  hysteria. 

In  the  sympathetic  variety  we  meet 
with  a  group  of  symptoms,  some  relating 
to  the  heart,  others  to  the  sexual  organs. 
Bradycardia,  with  a  slow  pulse  of  40  or 
50,  is  often  observed  to  occur  with  influ- 
enza; we  meet  with  an  irregular  or  in- 
termittent pulse  accompanied  by  attacks 
of  syncope;  occasionally  also  attacks  of 
the  nature  of  angina  pectoris  have  been 
noted  following  influenza,  where  there 
was  neither  gout  nor  arteriosclerosis,  or 
any  other  palpable  cause  for  the  attacks. 
In  some  cases  the  myocardium  is  most 
likely  also  affected,  which  may  account 
for  the  sudden  death  occurring  after  in- 
fluenza. 

Among  the  post-influenzal  nervous 
affections  of  an  organic  nature  is  most 
important  peripheral  neuritis.  Various 
forms  of  peripheral  neuritis  have  been  ob- 
served. In  a  few  cases  all  four  extremi- 
ties are  affected. 

Much  more  common  than  the  former  is 
a  more  limited  neuritis,  affecting  some- 
times only  one  limb  or  the  two  limbs  on 
one  side.  The  affection  comes  on  some 
days  or  a  week  after  the  recovery  from 
the  influenza,  the  patient  complaining  of 
more  or  less  severe  pain  in  the  limb,  some 
weakness  of  certain  groups  of  muscles 
comes  on;  in  the  lower  extremities  the 
anterior  group  of  muscles  of  the  leg  and 
flexors  of  the  knee  are  mostly  affected; 
in  the  upper  extremities  the  scapulo- 
humeral muscles,  or  sometimes  the  exten- 
sors of  the  wrist  and  fingers  become  in- 
volved; there  is  generally,  also,  disaes- 
thesia;  the  reflexes  are  first  increased, 
afterward  diminished,  but  rarely  become 
quite  absent.  Recovery  is  generally  very 
slow. 

A  third  form  resembles  diphtheritic  pa- 
ralysis. Here  there  is  paresis  of  accom- 
modation, and  in  some  few  cases  pharyn- 
geal and  laryngeal  paralysis,  and  it  is 
perhaps  a  nuclear  affection  rather  than  a 
peripheral  neuritis.  J.  Dreschfeld  (Med. 
Chron..  Mar..  '98). 


INFLUENZA.  DIAGNOSIS. 


37 


A  case  of  sclerosis  of  the  tongue  of  in-  ] 
fluenzal  origin.  The  middle  portion  of 
the  tongue  was  of  a  wooden  hardness. 
This  condition  followed  an  attack  of  in- 
fluenza in  a  person  of  middle  age.  The 
pathological  change  involved  the  cheeks 
also.  Iodide  had  no  effect  upon  the  dis- 
ease. Another  case  was  described  in 
which  the  tongue  had  assumed  an 
atrophic  and  mammillated  state  after  an 
attack  of  the  same  affliction.  M.  Cour- 
tade  (Laryngoscope,  Jan.,  '98). 

While  the  foregoing  history  and  symp-, 
toms  of  influenza  relate  to  its  true  epi- 
demic prevalence,  it  is  proper  to  state 
that  sporadic  cases,  presenting  all  the  j 
more  characteristic  symptoms,  are  met 
with  during  every  winter  in  the  temper- 
ate zone,  particularly  during  the  first 
two  or  three  days  of  high  temperature 
following  a  week  of  intense  cold. 

Diagnosis. — The  coincident  develop-  | 
ment,  without  premonition,  of  general  ! 
febrile  symptoms,  violent  pains  in  the  1 
head,  back,  limbs,  and  various  parts  of 
the  chest  or  abdomen,  catarrhal  irrita- 
tion of  the  membranes  of  the  respiratory 
passages  or  alimentary  canal,  or  both,  | 
with  mental  and  nervous  depression,  is 
so  characteristic  of  this  disease  as  to 
render  the  diagnosis  easy. 

[An  ordinary  attack  of  influenza  lasts 
from  three  to  ten  days;  of  dengue,  from 
one  to  three  weeks.  The  former  is 
marked  by  muscular  debility;  the  latter, 
by  intense  articular  pain,  especially  at 
the  knees,  occasioning  a  characteristic 
limping  gait.  Catarrhs  of  the  various 
mucous  membranes  constitute  the  rule  in 
influenza,  the  exception  in  dengue.  The 
latter  presents  a  characteristic  eruption. 
In  influenza  eruptions  are  rather  excep- 
tional, and,  when  present,  variable.  The 
temperature  of  dengue  is  apt  to  be  re- 
mittent and  higher  than  that  of  influ- 
enza. Convalescence  from  influenza  is 
generally  rapid;  from  dengue,  slow  and 
tedious. 

For  a  few  days  influenza  and  typhoid 
fever  might  be  confounded  with  one  an- 
other.   The  former,  however,  does  not 


present  the  dilated  pupil  so  often  seen 
in  the  latter,  nor  ever  a  rose  rash;  the 
temperature-curves  of  the  two  diseases 
are  distinctly  different,  and  the  charac- 
teristic stool  of  typhoid  fever  is  wanting 
in  influenza.  J.  C.  Wilson  and  S. 
Solis-Cohen,  Assoc.  Eds.,  Annual,  '91.] 

Peculiarity  of  the  tongue  observed  in 
cases  of  influenza,  and  which  is  believed 
to  be  characteristic.  It  consists  in  an 
appearance  of  porcelain-like  whiteness, 
associated  with  humidity.  The  colora- 
tion is  sometimes  uniform,  sometimes 
mottled.  It  makes  its  appearance  within 
the  first  two  or  three  days  of  the  attack, 
and  sometimes  persists  until  the  patient 
believes  himself  well.  Faisans  (Le  Bull. 
Med.,  May  28,  '93). 

Peculiar  vesicular  eruption  on  the  soft 
palate  considered  characteristic  of  influ- 
enza. The  eruption  consists  of  little  vesi- 
cles resembling  sago-grains,  of  from  0.5 
to  1.0  millimetre  in  diameter.  Shelly 
(Brit.  Med.  Jour.,  Apr.  15,  '93). 

Attention  drawn  to  a  peculiar  condi- 
tion of  the  tongue  noticed  in  cases  of  in- 
fluenza: the  appearance  of  dark,  purplish- 
red  spots  scattered  over  the  anterior  half 
of  the  dorsum,  about  the  size  of  a  pin's 
head,  becoming  white  and  vesicular  later 
on;  the  latter  also  noticed  on  the  inside 
of  the  mouth  and  soft  palate.  John 
Terry  (Lancet,  Oct.  12,  '95). 

Diagnosis  of  influenza  during  puerperal 
state.  Marked  and  repeated  chills;  se- 
vere pain  in  the  head,  body,  and  extremi- 
ties; gastric  and  pulmonary  disturb- 
ances. Pain  and  soreness  sufficiently 
characteristic  to  establish  the  differential 
diagnosis  between  it  and  puerperal  fever. 
T.  M.  Burns  (Annals  of  Gyn.  and  Ped., 
Sept.,  '95). 

Literature  of  '96-'97-'98. 

Symptoms  of  otitis  of  grippal  origin:  — 
1.  At  the  outset  of  the  otitis  phlyc- 
tenules filled  with  blood  appear  on  the 
tympanic  membrane,  and  sometimes 
cover  it  completely,  but  rarely  appear  on 
the  walls  of  the  auditory  canal.  When 
the  phlyctenules  break  and  blood  oozes 
from  them,  the  membrane  itself  is  at  first 
not  yet  broken  through  to  give  exit  to 
pus  from  within  the  tympanum. 


38 


INFLUENZA.  ETIOLOGY. 


2.  Perforation  occurs  through  a  kind  of 
baggy  prolapse  of  the  tympanic  mem- 
brane. 

3.  Tendency  to  early  complications 
with  processes  rapidly  destructive  in  the 
mastoid,  acute  caries  and  necrosis,  throm- 
bosis of  sinuses,  pyaemia.  Osteitis  may 
occur  at  the  outset,  developing  quietly 
without  accompanying  signs  of  inflamma-  ; 
tion  of  the  tympanic  cavity,  which  may 
be  invaded  later. 

4.  Persistence  of  pains  and  buzzings  of 
the  ear,  often  more  prolonged  after  the 
perforation  than  in  non-grippal  cases. 
The  membrane  once  more  healed  and  the 
scar  closed  by  cicatrix,  deafness  may  per- 
sist, though  repair  seems  perfect. 

These  four  characteristics,  even  in  the 
absence  of  bacteriological  confirmation, 
will  establish  the  diagnosis  from  non- 
grippal  otitis  media.  Loewenberg  (Le 
Bull.  Med.,  Mar.  2,  '98). 

The  fact  that  many  in  the  same  com- 
munity are  attacked  simultaneously  or 
in  quick  succession  renders  the  clinical 
diagnosis  more  complete;  yet  some  of  the 
first  cases  observed  are  generally  denom- 
inated violent  "colds,"  and  when  not 
severe  are  treated  with  domestic  reme- 
dies without  the  aid  of  a  physician. 

Etiology. — At  the  present  time  a  large 
majority  of  medical  writers  and  teachers 
assume  that  influenza  is  an  infectious 
disease,  caused  by  a  specific  bacillus.  And 
they  generally  point  to  the  bacillus  dis- 
covered in  the  pus-cells  of  the  tracheal 
mucus  by  Pfeiffer  in  1892,  and  in  the 
blood  by  Canon  the  same  year,  as  the 
essential  cause  of  this  disease.  To  the 
toxins  developed  by  this  micro-organism 
are  also  attributed  the  many  and  impor- 
tant complications  and  sequela?  that  ac- 
company or  follow  a  large  proportion  of 
the  attacks.  As  early  as  the  middle  of 
the  present  century  it  was  suggested  by 
Dr.  J.  K  Mitchell,  of  Philadelphia,  that  I 
the  disease  was  caused  by  minute  crypto- 
gamic  bodies  in  the  air.  In  1868  Dr.  j 
J.  N.  Salsbury,  of  Cleveland,  claimed  to 


have  discovered  a  species  of  infusorium 
in  the  nasal  discharges  of  a  considerable 
number  of  cases  which  he  regarded  as 
the  essential  cause  of  the  disease.  The 
extraordinary  rapidity  of  the  spread  of 
the  disease  over  whole  continents  led 
nearly  all  of  the  older  writers  to  attribute 
it  to  sudden  and  extreme  changes  in  tem- 
perature, moisture,  and  electric  condi- 
tions of  the  atmosphere,  but  no  uniform- 
ity of  such  changes  has  been  found  in 
different  epidemics. 

Influenza  is  independent  of  hygro- 
metric,  thermometric,  and  barometric 
changes.  Greenley  (Amer.  Pract.  and 
News,  Mar.  15,  '90). 

Atmospheric  conditions  bear  an  im- 
portant relation  to  the  spread  of  the  in- 
fecting agent;  the  micro-organisms  are 
carried  high  up  by  the  warm  currents 
and  are  precipitated  again  to  the  stratum 
in  which  they  are  effective  by  the  eddies 
which  the  cold  currents  produce.  Ucke 
(St.  Petersburger  med.  Woch.,  Feb.  17, 
'90). 

Transmission  of  the  disease  from  per- 
son to  person  is  the  exception;  the  dis- 
semination of  the  disease  is  accomplished 
through  the  atmosphere.  Combe  (Revue 
Med.  de  la  Suisse  Rom.,  May  20,  '90). 

Influenza  is  neither  contagious  nor  im- 
ported from  other  localities  than  those 
in  which  it  appears,  but  the  microbe  of 
influenza  is  identical  with  that  of  simple 
coryza,  which  has  attained  its  "sum mum 
potent  iw"  through  favorable  telluric  or 
climatic  conditions,  such  as  those  of  tem- 
perature or  humidity  of  the  atmosphere. 
Otremba  (Bull,  de  la  Soc.  des  Med.  et 
Nat.  de  Jassy,  Nov.  3,  '90). 

Influenza  is  a  specific  disease  occurring 
under  conditions  constantly  the  same, 
due  to  atmospheric  influences  and  com- 
plicated by  the  pathogenic  germs  at 
hand.  Kowalski  (Wiener  klin.  Woch.. 
Apr.  3,  '90). 

Influenza  is  a  paresis,  or  partial  paraly- 
sis, of  the  pneumogastric  nerve,  depend- 
ing probably  on  such  a  sudden  change  in 
the  atmosphere  as  involves  an  increased 
expenditure  of  force  in  maintaining  circu- 
lation and  respiration.  The  best  remedies 


INFLUENZA. 

are  strong  excitomotor  stimulants,  chief 
among  them  strychnine,  caffeine,  alcohol, 
and  ammonia.  Morris  (Jour.  Amer. 
Med.  Assoc.,  Jan.  3,  '91). 

The  infection  is  due  to  a  miasmatic 
chemical  material  derived  from  the  at- 
mosphere. Leyden  (Deutsche  med.-Zeit., 
Feb.  27,  "90). 

Miasmatic  origin  supported.  Osier 
(Amer.  Jour,  of  the  Med.  Sci.,  Apr.,  '90). 

In  the  district  prison  at  Freiburg:  Of 
400  prisoners,  35  per  cent,  were  stricken ; 
of  those  in  solitary  confinement,  30  per 
cent.;  of  those  in  the  common  wards, 
50  per  cent.;  of  those  in  communication 
with  the  outer  world,  70  per  cent.  The 
restriction  of  the  outbreak  to  different 
corridors  shows  that  it  was  not  due  to  a 
miasmatic  influence.  Kirn  (Aerztliche 
Mittheil.  aus  Baden,  Karlsruhe,  vol.  xliv, 
No.  7,  '90). 

Operation  on  the  nose  should  not  be 
performed  during  an  epidemic  of  influ- 
enza, as  operations  usually  cause  a  re- 
lapse, with  marked  depression.  The 
wound  invites  infection.  Delavan  (N.  Y. 
Med.  Jour.,  June  8,  '95). 

There  can  be  no  influenza  without 
Pfeiffer's  bacillus.  De  Eenzi  (La  Clin. 
Mod.,  Dec,  '95). 

Literature  of  '96-'97-'98. 

The  influenza  bacillus  is  capable  of  giv- 
ing rise  to  fibrous,  serous,  or  even  hsemor- 
rhagic,  exudate  in  the  lungs,  which  may 
become  purulent.  When  the  sinuses  com- 
municating with  the  nose  are  inflamed 
it  is  nearly  always  a  result  of  infection 
with  the  influenza  bacillus.  Lindenthal 
(Wien.  klin.  Woch.,  April  15,  '97). 

The  inmates  of  insane  asylums  are  less 
liable  to  be  affected  with  influenza  at 
the  time  of  an  epidemic  than  the  inmates 
of  other  large  institutions,  such  as  bar-  j 
racks,  workhouses,  etc. 

An  attack  of  influenza  does  not  ma- 
terially affect  the  disease  from  which  the 
insane  patient  at  the  time  suffered,  yet 
in  some  cases  the  effect  was  a  beneficial 
one.  J.  Dreschfeld  (Med.  Chronicle, 
Mar.,  '98). 

Careful  meteorological  observations 
and  records  kept  in  Chicago  during  the 
prevalence  of  the  epidemic  of  1889-'90 


ETIOLOGY.  39 

showed  the  presence  in  the  air  of  a  de- 
cided excessive  amount  of  both  free  and 
albuminoid  ammonia,  with  almost  entire 
absence  of  ozone.  Whether  such  condi- 
tions of  the  atmosphere  could  foster  the 
rapid  evolution  of  the  bacillus  of  Pf eiff er 
could  be  determined  only  by  similar  rec- 
ords kept  through  both  epidemic  and 
non-epidemic  periods.  That  the  disease 
is  caused  by  some  infectious  or  bacterial 
agent,  capable  of  rapid  development  and 
wide  diffusion  in  the  air,  is  proved  by  the 
suddenness  of  its  attack,  the  large  num- 
ber attacked  at  the  same  time  in  a  com- 
munity without  any  communication  with 
each  other,  and  its  simultaneous  out- 
break in  places  widely  separated  from 
each  other.  Thus,  in  the  last  great  epi- 
demic, beginning  in  the  autumn  of  1889, 
it  was  recognized  in  St.  Petersburg  in 
October,  in  Central  Europe  in  Novem- 
ber, and  in  England,  Massachusetts,  Con- 
necticut, New  York,  Pennsylvania, 
Ehode  Island,  Ohio,  Indiana,  Illinois, 
Wisconsin,  and  Kansas  during  the  last 
week  of  December,  1889  (see  Jour.  Amer. 
Med.  Assoc.,  volume  xiv,  pp.  817-822). 
To  the  same  import  is  the  fact  that  the 
passengers  and  crew  on  board  of  ships 
have  been  attacked  on  the  ocean  two 
weeks  after  any  communication  with  the 
land.  And  also  the  fact  that  hermits 
and  other  persons  in  complete  isolation 
have  suffered  severe  attacks  at  the  same 
time  with  those  in  the  general  commu- 
nity. The  bacillus  discovered  by  Pfeiff er, 
and  claimed  to  be  the  essential  cause  of 
influenza,  is  very  small,  non-motile,  and 
stains  well  with  methylene-blue. 

It  is  found  in  great  numbers  in  the 
nasal  and  bronchial  muco-purulent  dis- 
charges during  the  active  progress  of  the 
disease,  and  sometimes  remains  in  those 
localities  several  weeks  after  the  recovery 
of  the  patient.  It  has  been  found  pene- 
trating other  tissues  and  in  the  blood, 


40  INFLUENZA. 

though  much  less  abundantly,  and  on 
culture-media  it  is  said  to  grow  only  in 
the  presence  of  haemoglobin. 

The  bacilli  of  influenza  appear  as  very 
tiny  rods  of  about  the  thickness  of  the 
bacilli  of  mouse-septicaemia,  but  only 
half  the  length  of  these.  Often  three  or 
four  bacilli  are  strung  together  in  the 
form  of  a  chain.  They  stain  with  some 
difficulty  with  the  basic  aniline  dyes. 
Better  preparations  are  obtained  with 
dilute  Ziehl's  solution  or  with  hot 
Loffler's  methylene-blue.  In  this  way  it 
can  be  seen,  almost  as  a  rule,  that  the 
two  ends  of  the  bacilli  take  the  stain 
more  intensely  than  the  centre;  so  that 
forms  are  produced  that  can  with  diffi- 
culty be  distinguished  from  diplococci  or 
streptococci.  They  cannot  be  stained  by 
Gram's  method.  In  hanging  drops  they 
are  immobile.  Pfeiffer  and  Kitasato  and 
Canon  (Deutsche  med.  Woch.,  Jan.,  '92). 

In  a  series  of  observations  of  influenza, 
embracing  about  30  cases,  the  diplococcus 
pneumoniae  of  Fraenkel  and  Weichsel- 
baum  was  the  predominant  form.  In  six 
series,  embracing  60  or  more  cases,  strep- 
tococcus pyogenes  were  found  in  the 
lungs,  sputum,  and  other  secretions,  and 
in  various  exudations. 

They  probably  have  not  been  the  cause 
of  the  influenza,  but  have  developed  as 
the  influenza  has  provided  them  with  a 
suitable  condition  for  growth,  and  this 
development  may  have  caused  some  of 
the  complications.  Dowd  (Med.  Rec, 
Mar.  29,  '90). 

Influenza  microbe  can  easily  be  culti- 
vated; appears,  in  different  stages  of  its 
growth,  as  a  diplococcus,  a  bacillus,  or  a 
streptobacillus;  appears  not  only  in  the 
blood,  but  also  in  the  various  tissues. 
Trouillet  (Med.  Press  and  Circ,  Mar.  6, 
'95). 

Literature  of  '96-'97-'98. 

The  influenza  bacillus,  0.5-1x3  microns, 
reacts  peculiarly  to  staining  agents,  the 
poles  being  deeply  stained,  with  an  un- 
stained equator,  thus  causing  a  close  re- 
semblance to  a  diplococcus.  It  is  readily 
stained  with  dilute  carbol-fuchsin,  or 
Loffler's  blue  solution.  It  is  difficult  of 
cultivation,  but  there  can  be  no  diffi- 


PATHOLOGY. 

culty  in  detecting  it  on  cover-slips  of  the 
catarrhal  secretion.  Eugene  Wasdin 
(Penna.  Med.  Jour.,  Nov.,  '97). 

Pathology. — Ordinary  post-mortem  ex- 
aminations reveal  no  structural  changes 
peculiar  to  this  disease.  There  are  con- 
gested and  inflammatory  conditions  of 
the  mucous  membrane  either  of  the  re- 
spiratory passages  or  of  the  digestive 
organs,  or  both.  In  some  cases  such 
inflammations  have  extended  into  the 
frontal  sinuses,  the  maxillary  antrum, 
and  to  the  middle  ear,  and  in  more  cases 
there  are  evidences  of  pneumonia. 

Ocular  lesions  seen  in  influenza  are 
manifold,  but,  if  any  predilection  is 
shown,  it  is  for  the  optic  nerve  and  ret- 
ina, and  for  the  various  periorbital 
sinuses.  In  panophthalmitis  enucleation 
should  be  deferred  when  the  infection  is 
from  a  general  cause  and  the  patient  is 
in  bad  condition;  but  when  the  origin  is 
local  and  the  general  condition  is  good 
it  should  be  performed  at  once.  Panas 
(Revue  Gen.  de  Clin,  et  de  Ther.  Jour, 
des  Prat.,  Apr.  20,  '95). 

Eye  complications  following  grip  are 
comparatively  rare.  Grip  may  affect  the 
eye  by  inflammatory  process  or  by  inva- 
sion of  the  accessory  sinuses.  It  may 
affect  the  nervous  tissues.  The  inflam- 
matory affections  involve  especially  the 
conjunctiva,  the  uveal  tract,  tissues  of 
the  orbit,  and  perhaps  the  fibrous  cap- 
sule of  Tenon.  The  nervous  apparatus 
of  the  eye  is  especially  liable  to  become 
involved  by  paresis  of  accommodation  or 
of  the  extrinsic  muscles  of  the  cervical 
sympathetic,  by  papillitis  and  retrobular 
neuritis,  and  also  anaesthesia  of  the  cor- 
nea may  occur.  Pooley  (Amer.  Jour,  of 
Ophthal.,  May,  '95). 

One  hundred  cases  of  aural  and  cu- 
taneous complications  seen  in  epidemic 
of  influenza.  Although  very  painful,  the 
patients  spending  sleepless  days  and 
nights  from  the  agonizing  pains  shooting 
through  the  head  and  shoulders,  the 
cases,  as  a  rule,  ended  in  complete  re- 
covery in  a  comparatively  short  time. 
Eitelberg  (Brit.  Med.  Jour.,  July  19,  '90). 

Hemorrhagic  otitis  media  described  as 


INFLUENZA.    PATHOLOGY.  PROGNOSIS. 


41 


characteristic  of  the  epidemic.  It  sets  in 
between  the  third  and  seventh  day  of  the 
disease,  and  is  attended  with  hsemor- 
rhagic  effusion  into  the  tympanum,  mani- 
fested by  intense  pain.  Spontaneous  per- 
foration usually  takes  place  in  the  course 
of  twelve  hours.  Haug  (Munch.  Med. 
Woch.,  Jan.  21,  '90). 

Literature  of  '96-'97-'98. 

The  presence  of  the  influenza  bacillus 
exerts  a  very  unfavorable  influence  on 
the  bony  structures  of  the  ear,  often  con- 
verting apparently  very  simple  cases  of 
acute  suppurative  otitis  into  very  malig- 
nant ones,  with  rapid  destruction  of  bone, 
and  this  without  marked  symptoms. 
This  tendency  to  rapid  bone-destruction 
should  be  constantly  kept  in  mind,  and 
can  be  prevented  only  by  early  and,  if 
necessary,  repeated  paracentesis.  Wells 
P.  Eagleton  (N.  Y.  Med.  Jour.,  Aug.  7, 
597). 

But  all  these  are  regarded  rather  as 
complications  than  as  essential  features 
of  the  general  disease.  The  general  feb- 
rile symptoms  appear  to  result  from  the 
direct  action  of  the  bacillus  or  its  pto- 
maines on  the  corpuscular  elements  of 
the  blood  and  of  the  cerebral-nerve  cen- 
tre, creating  great  pain  and  soreness, 
with  marked  depression  and  impairment 
of  vital  resistance.  This  view  is  sus- 
tained by  A.  Cantani,  Jr.,  who  injected 
cultures  "  of  the  influenza  bacillus  into 
the  brain  of  rabbits,  by  which  severe 
nervous  symptoms  were  produced,  and 
from  which  he  inferred  the  bacillus  to 
be  an  intracellular  poison  acting  primar- 
ily on  the  central  system. 

In  post-influenzal  meningitis  no  lesion 
whatever  to  be  found  at  necropsy,  either 
in  brain  or  medulla.  In  rare  cases,  sup- 
purating lesions  of  the  brain  and  menin- 
ges found.  T.  C.  Maxime  (Lancet,  Apr. 
13,  '95). 

Literature  of  '96-'97-'98. 

Effect  of  intracranial  inoculation  of 
the  influenza  bacillus  in  rabbits  studied. 


Virulent  cultures  were  introduced  into 
the  brain  by  trephining.  Severe  nervous 
symptoms,  high  temperature,  and  death 
followed  in  about  twenty-four  hours. 
At  the  autopsy  at  the  site  of  the  wound 
was  an  oedema  containing  numerous  in- 
fluenza bacilli  and  haemorrhages.  The 
meninges  were  hyperaemic  and  infiltrated 
with  hsemorrhagic  exudation.  The  brain 
was  markedly  hyperaemic,  the  ventricles 
often  containing  a  purulent  exudation 
in  which  numerous  influenza  bacilli  were 
found.  The  substance  of  the  brain,  on 
section,  showed  many  small  haemorrhages 
and  numerous  bacilli,  with  polynuclear 
leucocytes.  The  bacilli  appeared  to 
spread,  especially  by  the  lymph-channels. 
The  spinal  cord  was  also  invaded  to  a 
slight  extent,  the  bacilli  passing  by  the 
way  of  the  central  canal.  The  processes 
were  generally  those  of  a  myelitis,  simi- 
lar to  the  encephalitis  of  the  brain,  but 
not  nearly  so  severe.  The  other  lesions 
present  were  bloody,  serous  exudate  in 
the  peritoneal  cavity,  acute  congestion 
of  the  spleen,  hyperemia  of  the  kidney, 
small  haemorrhages  into  the  suprarenal 
bodies,  and  incipient  fatty  degeneration 
of  the  liver.  The  lungs  were  injected. 
Practically  the  same  results  could  be  ob- 
tained by  inserting  a  few  milligrammes 
of  the  dead  growth  of  the  bacilli  (killed 
by  heat)  beneath  the  dura  mater.  This 
proves  that  the  toxins  are  the  really  ac- 
tively hurtful  agents.  Cantani  (Zeit.  f. 
Hyg.  u.  Infect.,  B.  13,  '96). 

Three  cases  of  influenza  which  termi- 
nated fatally,  in  which  the  presence  of 
Pfeiffer's  bacilli  in  the  nervous  centres 
was  ascertained.  A.  Pfuhl  (Zeits.  f.  Hyg. 
u.  Infect.,  p.  112,  '97). 

Prognosis. — The  mortality  from  un- 
complicated cases  of  influenza  is  very 
small,  probably  not  exceeding  0.25  of  1 
per  cent.  While  this  is  true,  it  is  equally 
true  that  during  the  prevalence  of  an 
influenza  epidemic  the  mortality  from 
tuberculosis,  pneumonia,  bronchitis,  and 
typhoid  fever  is  greatly  increased. 

[Of  528  deaths  attributed  to  influenza, 
46  resulted  from  the  uncomplicated  dis- 
ease, 39  from  senility,  49  from  phthisis, 


4:2 


INFLUENZA.    PROGNOSIS.  TREATMENT. 


273  from  croupous  and  broncho-pneu- 
monia, 81  from  other  affections  of  the 
lungs,  5  from  pleurisy,  and  2  from  em- 
pyema. Thirty-three  deaths  were  noted 
from  cerebral  affections  in  the  course  of 
influenza.  Axel  Ulrik,  Cor.  Ed.,  An- 
nual, '91.] 

During  the  three  months — January, 
February,  and  March,  1890 — constitut- 
ing the  period  of  active  prevalence  of  the 
epidemic  for  that  year  the  number  of 
deaths  reported  to  the  Eegister  of  Vital 
Statistics  of  Chicago,  from  the  four  dis- 
eases just  named,  were  nearly  100  per 
cent,  greater  than  during  the  correspond- 
ing months  of  the  preceding  year.  The 
effect  in  diminishing  the  normal  vital  re- 
sistance is  longer  manifest  in  regard  to 
typhoid  fever  and  tuberculosis  than  in 
any  other  general  diseases.  One  attack 
affords  no  immunity  to  subsequent  at- 
tacks of  the  influenza,  and  there  are  no 
known  prophylactic  measures  of  value. 

Marked  immunity  from  influenza  ob- 
served among  the  inhabitants  of  Madeira 
who  had  been  recently  vaccinated.  In 
the  epidemic  of  influenza  those  that  had 
been  vaccinated  remained  free,  while 
those  that  had  not  been  vaccinated  were 
rapidly  infected.  This  fact  suggested  as 
an  explanation  of  the  comparative  in- 
frequency  of  influenza  among  children. 
Goldschm-idt  (Berl.  klin.  Woch.,  Dec.  8, 
'90). 

Of  241  cases  of  influenza,  86  had  re- 
cently been  vaccinated.  Bienfait  (Union 
Med.  du  Nord-est,  Apr.,  '91). 

Literature  of  '96-'97-'98. 

The  influenza  bacillus,  like  the  strepto- 
coccus, the  diplococcus,  and  a  few  other 
pathogenic  bacteria,  is  of  such  a  nature 
that  immunity  cannot  be  attained. 
Delius  and  Kolle  (Zeit.  f.  Hyg.  u.  Infect., 
Apr.  13,  '97). 

The  rate  of  relapse  in  influenza  is  not 
less  than  10  per  cent.  A  previous  attack 
rather  predisposes  than  immunizes,  and, 
if  protection  be  afforded,  it  is  so  short  as 
to  be  clinically  negligible.  Turney  (Lan- 
cet, Feb.  5,  '98). 


Treatment.  —  The  discovery  of  the 
bacillus  by  Pfeiffer  as  the  supposed  spe- 
cific cause  of  influenza  has  not  been  fol- 
lowed by  the  discovery  of  a  special  rem- 
edy, either  for  its  destruction  or  for 
reliably  counteracting  its  effects  upon 
the  human  system.  Consequently  we 
must  be  guided  in  our  choice  of  reme- 
dies by  the  prominent  functional  dis- 
turbances presented  in  each  case.  These 
are  generally  diminished  eliminations 
from  the  skin  and  kidneys;  congestion 
of  the  mucous  membranes,  especially  of 
the  nasal  and  respiratory  passages;  and 
severe  pains  and  soreness  throughout  the 
nervous  and  muscular  structures  of  the 
body.  To  allay  the  pains  and  soreness 
and  restore  more  active  eliminations 
from  the  skin,  kidneys,  and  intestines 
are  the  rational  indications  to  guide  us 
in  the  choice  of  remedies.  If  called  in 
the  early  stage  of  the  disease,  in  all  the 
milder  cases  a  single  powder — contain- 
ing from  15  to  8  grains  of  Dover's  pow- 
der, 3  grains  of  calomel,  and  3  grains  of 
pulverized  gum-camphor — given  at  bed- 
time and  followed  in  the  morning  by  a 
saline  laxative  sufficient  to  produce  two 
or  three  intestinal  evacuations  has  very 
generally  relieved  all  the  more  important 
symptoms;  and  by  giving  3  grains  of 
quinine  sulphate  three  times  a  day  for 
three  or  four  days  the  convalescence  has 
been  complete. 

Sulphate  of  quinine  strongly  recom- 
mended in  the  treatment  of  influenza. 
Large  doses  should  be  administered  in 
accordance  with  the  age  and  tempera- 
ment of  the  patient  and  the  severity  of 
the  attack.  Gelle  (Jour,  de  Med.  do 
Bordeaux,  Mar.  9,  '90). 

Best  results  obtained  from  diaphoresis 
followed  by  quinine.  Combination  of 
pilocarpine  and  morphine  found  to  act 
better  than  antipyrine:  — 

I£  Pilocarpine  hydrochlorate,  V;  grain. 
Morphine  sulphate,  %  grain. 
Water,  3  ounces. 


INFLUENZA.  TREATMENT. 


43 


M.  Sig. :  A  teaspoonful  every  fifteen 
minutes,  by  mouth.  Wood  (University 
Med.  Mag.,  Mar.,  '90). 

At  the  outset  of  an  epidemic  every 
member  of  his  battalion  given  4 1/2  grains 
of  sulphate  of  quinine  daily,  and  ma- 
noeuvres in  the  open  air  forbidden.  This 
was  continued  for  twelve  days.  While 
the  epidemic  spread  in  the  immediate 
vicinity  of  the  barracks,  few  of  the  sol- 
diers were  affected.  Similar  good  re- 
sults, however,  were  not  had  when  the 
disease  already  existed.  Then  antipyrine 
rendered  the  greatest  service.  Tranjen 
(Berl.  klin.  Woch.,  Feb.  17,  '90). 

Quinine  sulphate  has  no  apparent 
effect  in  modifying  the  course  of  an  un- 
complicated attack  of  influenza.  Thomp- 
son (Va.  Med.  Monthly,  Aug.,  '91). 

Quinine  has  a  decided  effect  in  reliev- 
ing the  neuralgic  symptoms.  Ingals 
(Jour.  Amer.  Med.  Assoc.,  Oct.  10,  '91). 

Quinine  believed  to  have  a  specific  ac- 
tion in  influenza.  Fractional  doses  must 
not  be  given,  but  one  massive  dose  for 
the  entire  day,  preferably  in  solution. 
Graeser  (Deutsche  med.  Woch.,  No.  51, 
'93). 

Rabbits  inoculated  with  blood  of  influ- 
enza patients,  pure  cultures  of  microbe, 
and  with  blood  and  cultures  obtained 
from  inoculated  animals,  and  then  with 
solution  of  quinine.  Results  showing 
controlling  action  of  quinine.  Mosse 
(Revue  de  Med.,  Mar.  1,  '95). 

Quinine  not  completely  excreted  from 
tissues  for  some  days ;  3  to  5  grains  in  an 
effervescing  saline  draught  every  three  or 
four  hours  controls  the  course  of  influ- 
enza. Large  doses  unnecessary;  they 
produce  marked  cardiac  depression,  par- 
ticularly in  elderly  people.  Marsh  (Lan- 
cet, Mar.  9,  '95). 

Quinine  given  at  proper  time  and  in 
large  enough  doses  will  prevent  an  out- 
break of  the  disease.  Given  to  one  of 
five  squadrons  of  cavalry,  7  V2  grains  I 
daily.  Only  7  men  in  squadron  con-  ' 
tracted  influenza;  in  other  four  squad- 
rons 22,  19,  32,  and  42  cases,  respectively, 
suffered.  Graeser  (Inter,  klin.  Rund., 
Nov.  10,  '95). 

Quinine  an  almost  unexceptionable 
preventive  of  influenza;  5  grains  im- 
mediately after  breakfast  during  preva- 


lence of  epidemic.  Sinclair  Coghill  (Brit. 
Med.  Jour.,  Apr.  6,  '95). 

Literature  of  '96-'97-'98. 

Internal  administration  of  carbolic  acid 
recommended  in  cases  of  a  mild,  iregular 
type  of  influenza.  After  an  experience 
of  three  hundred  cases  the  writer  pro- 
nounces it  very  efficacious.  The  dose 
given  was  a  teaspoonful  of  a  1-per-cent. 
solution  for  a  child  of  5  years,  adminis- 
tered every  two  hours  until  decided  im- 
provement was  noticed,  and  afterward 
at  longer  intervals.  S.  H.  Dessau  (Med. 
Rec,  Sept.  12,  '96). 

Calomel  is  an  exceedingly  useful  drug 
in  the  early  stages  of  an  attack  of  in- 
fluenza. The  dose  to  be  given  amounts 
to  2  grains  twice  a  day  to  adults,  or  1 
grain  three  or  four  times  a  day.  In  in- 
fants smaller  doses  are  given,  according 
to  age.  Cure  can  usually  be  produced 
by  the  third  day.  Frudenthal  (Therap. 
Monat.,  Oct.,  '97). 

Treatment  is  mostly  symptomatic.  In 
the  beginning  calomel  in  doses  of  from  2 
to  5  grains  for  adults  (one-tenth  that 
amount  for  children)  should  be  given. 
The  calomel  is  divided  into  three  pow- 
ders, given  at  intervals  of  an  hour.  As 
long  as  the  fever  lasts,  rest  and  a  fever 
diet  are  indicated.  Salipyrin,  15  grains 
every  evening,  and  in  the  morning  half 
that  amount,  to  be  given.  With  this 
remedy  almost  phenomenal  results  are 
obtained.  Salipyrin  must  be  continued 
for  some  time  in  order  to  achieve  a  good 
result.  Ten  grains  prescribed  at  night 
for  from  three  to  five  days  after  the  fever 
has  disappeared.  Even  after  the  tem- 
perature has  fallen  to  the  normal  the 
patient  should  be  confined  to  his  room 
for  a  number  of  days.  Bekess  (Wiener 
med.  Presse,  Aug.  15,  '97). 

Kryofin  used  as  an  antipyretic  in  six- 
teen cases  of  influenza.  It  prevents  a 
rise  of  temperature  instead  of  reducing 
a  temperature  already  elevated.  Seven 
grains  and  a  half  may  be  given  daily. 
Bresler  (Ther.  Monat.,  Oct.,  '97;  Brit. 
Med.  Jour.,  Nov.  27,  '97). 

The  pressing  indication  to  be  met  in 
asthenic  patients  lies  in  the  state  of  their 
forces,  which  need  sustenance.  Stimu- 
lating remedies  should  occupy  the  first 


44 


INFLUENZA.  TREATMENT. 


place.  Thus,  alcoholic  liquors,  diffusible 
stimulants,  and  tonics  should  be  made 
the  basis  of  medication.  The  salts  of 
quinine,  selected  and  administered  with 
judgment,  will  not  only  control  many  of 
the  pains  of  the  disease,  but  will  relieve 
the  weakness  and  stimulate  the  patient. 
Landouzy  (La  Presse  Med.,  Jan.  29,  '98). 

The  following  combination  highly 
recommended  for  influenza  ushered  in  by 
severe  fever  and  nervous  disturbances:  — 

I£  Quin.  salicyl.,  3  grains. 
Phenacetin,  2  grains. 
Camphor,  1/3  grain. — M. 
The  above  dose  to  be  administered  up 
to  six  times  in  twenty-four  hours.  Bae- 
celli  (Gaz.  degli  Osp.  e  delle  Clin.,  No.  43, 
'98). 

In  the  more  severe  cases,  instead  of  one 
powder  at  bed-time,  the  same  should  be 
given  every  four  hours  until  four  have 
been  taken,  then  move  the  bowels  with 
the  laxative  and  follow  with  moderate 
doses  of  quinine,  alternated  with  5-grain 
doses  of  sodium  salicylate,  until  all 
the  active  symptoms  have  disappeared. 
When  the  bronchial  symptoms  have  been 
persistent,  with  soreness  in  the  chest, 
instead  of  the  sodium  salicylate  I  have 
given,  with  very  good  results,  a  teaspoon- 
ful  of  the  following  mixture  every  four 
or  six  hours  until  the  chest  symptoms 
were  relieved: — 

I£  Hydrochlorate  of  ammonia,  31/2 
drachms. 
Ant.  et  potass,  tart.,  2  grains. 
Mercuric  bichloride,  2  grains. 
Morph.  sulph.,  3  grains. 
Syr.  of  licorice,  5  ounces. — M. 

When  the  influenza  has  induced  at  the 
beginning  so  much  irritation  of  the  gas- 
tric and  intestinal  mucous  membrane 
that  the  powders  of  Dover's  powder 
and  camphor  cannot  be  retained,  I  have 
given  instead  4  y2-grain  doses  of  salol 
aided  by  1  1/2  or  3  grains  of  calomel  at 
uight  for  the  first  two  days  with  entirely 


satisfactory  results.  Then  smaller  doses 
of  the  salol,  alternated  with  very  moder- 
ate doses  of  quinine,  has  been  all  the 
medication  necessary  to  complete  the  re- 
covery of  the  patient.  In  all  cases,  dur- 
ing the  active  stage  the  patient  has  been 
kept  at  rest,  and,  as  far  as  practicable, 
in  a  well-ventilated,  warm,  but  not  over- 
heated room. 

In  the  exudative  form  of  aural  com- 
plications, when  the  pain  is  severe,  local 
blood-letting  in  the  temporal  region,  ice- 
bags  behind  or  about  the  ear,  and,  in 
some  cases,  iodine  locally  to  the  mastoid, 
forms  the  treatment.  Subsequently,  if 
paracentesis  cannot  be  performed,  warm 
instillations  into  the  external  auditory 
canal  to  be  made  hourly.  If  the  pain 
increases  and  the  temperature  rises  while 
exudation  is  detected  in  the  middle  ear, 
with  pain  and  sensitiveness  in  the  mas- 
toid region,  paracentesis  affords  the 
greatest  relief.  Inflation  to  be  practiced, 
the  canal  syringed  with  an  antiseptic 
solution  and  packed  with  gauze.  Haug 
(Munch,  med.  Woch.,  Feb.  25,  '90). 

Faradic  brush  recommended  in  treat- 
ment of  the  neuralgias  of  influenza.  The 
painful  nerve  is  included  between  the 
two  buttons  of  a  brush  especially  con- 
structed for  the  purpose,  or  between  two 
ordinary  wire  brushes,  kept  stabile,  and 
a  faradic  current,  at  first  weak,  but  grad- 
ually increased  in  intensity.  The  appli- 
cation lasts  from  half  a  minute  to  two 
minutes.  From  eight  to  thirty  stances 
are  necessary.  Nothnagel  (Zeit.  f.  klin. 
Med.,  vol.  xvii,  Nos.  3,  4,  '90). 

Rapid  relief  obtained  from  the  head- 
ache and  the  general  nervous  and  diges- 
tive symptoms  from  the  employment  of 
copper  arsenic  in  doses  of  l/m  grain. 
Johnson  (Med.  Summary,  June,  '91). 

Salicin,  20  to  40  grains  prescribed 
every  hour,  for  three  or  six  hours;  then, 
every  two  hours,  for  a  day;  after  that, 
at  long  intervals.  Convalescence  com- 
menced in  twenty-four  hours  in  all  cases, 
and,  in  most,  in  twelve  hours.  There 
were  no  serious  complications.  Maclagen 
(Lancet,  Jan.  11,  '90). 
I  Administration  of  large  doses  of  sali- 


INFLUENZA.  TREATMENT. 


cin,  20  grains  every  hour,  advocated. 
Turner  (Lancet,  July  18,  '91). 

Of  all  antineuralgic  remedies  tried, 
salophen  proved  the  most  useful.  Sepa- 
rates into  salicylate  of  soda  and  acetyl- 
paramidophenol  in  alkaline  contents  of 
the  small  intestine;  odorless  and  taste- 
less. Hennig  (Munch  med.  Woch.,  Sept. 
3,  '95). 

Salicylate  of  soda,  2  or  3  grains  every 
three  hours  to  older  children.  Maltine 
with  coca-wine  for  neurasthenic  condi- 
tions. W.  L.  Stowell  (Arch,  of  Ped.,  Oct., 
'95). 

Twenty  cases  of  influenza  attended 
with  neuralgic  pains  greatly  ameliorated 
by  15  to  30  grains  of  salophen.  Recovery 
within  two  days.  Salophen  embodies  ad- 
vantages of  salicylate  of  soda  without 
possessing  its  disadvantages.  Claus  (Med. 
Bull.,  May,  '95). 

Literature  of  '96-'97-'98. 

No  drug  has  given  more  favorable  re- 
sults in  the  treatment  of  influenza  than 
benzoate  of  soda.  It  may  be  given  in 
capsule  or  powder  form,  the  usual  dose 
being  10  grains,  three  or  four  times  a 
day.  When  muscular  symptoms  are  pro- 
nounced, the  following  combination  acts 
admirably:  — 

R>  Sodii  benzoas,  2  drachms. 
Salol,  1  drachm. 
Phenacetin,  36  grains. 
M.  et  ft.  chart  No.  xij. 
Sig. :    One  powder  every  four  hours. 
Editorial  (Amer.  Med.-Surg.  Bull.,  Nov. 
25,  '97). 

For  influenza  in  children  salipyrin  is  an 
efficient  remedy.  For  a  child  of  five  years 
the  dose  is  4  grains,  and  for  one  of  ten 
years  8  grains,  to  be  administered  three 
times  daily.  Editorial  (Med.  News,  Mar. 
19,  '98). 

The  pharyngitis  and  rhinitis,  which  are 
often  the  most  troublesome  symptoms  of 
influenza  in  childhood,  are  treated  by 
pulverizations.  For  this  purpose  a  2-per- 
cent, alcoholic  solution  of  rectified  tur- 
pentine is  preferred.  Furst  (Rev.  Mens, 
des  Mai.  de  l'Enfanee,  Jan.,  '98). 

Yerba  santa  prescribed  in  cases  of 
cough  supervening  on  influenza,  with 
good  results.   Dose  of  fluid  extract,  10  to 


40  minims,  combined  with  extract  of 
malt,  as  malto-yerbine, — dose,  1  to  4 
drachms.  Joseph  Westmorland  (Lancet, 
Apr.  23,  '98). 

In  only  a  very  few  instances  has  the 
fever  temperature  reached  104°  F.,  and 
when  it  did  it  was  readily  reduced  by 
free  sponging  of  the  surface  or  a  few 
doses  of  aconite  or  veratrum  viride.  The 
diet  should  be  light  and  carefully  ad- 
justed to  the  ability  of  the  digestive  or- 
!  gans  to  receive  and  appropriate  it.  When 
|  pneumonia  or  any  other  complicating 
|  disease  supervenes,  for  which  the  practi- 
tioner should  always  be  on  the  alert,  it 
should  be  treated  promptly  and  on  the 
same  principles  as  would  govern  its  treat- 
ment under  other  circumstances. 

For  the  cephalalgia  and  rachialgia  a 
blister  to  the  nucha  recommended.  The 
pulmonary  hyperemia  may  be  relieved 
by  a  like  application  to  the  chest.  Con- 
valescence requires  quinine.  Peter  (Le 
Bull.  Med.,  Jan.  19,  '90). 

Attention  called  to  the  usefulness  of 
mustard,  in  the  form  of  sinapisms,  for 
the  treatment  of  troublesome  cough  in 
influenza.  Pavel  M.  Gorodtzoff  (Wratsch, 
No.  32,  '91). 

Ammonium  chloride  found  superior  to 
quinine  in  the  pulmonary  form.  Ma- 
rotte  (Gaz.  Hebd.  des  Sci.  Med.  de  Bor- 
deaux, June  21,  '91). 

Case  of  influenza  which  terminated  in 
pneumonia.  When  fatal  results  were  ex- 
pected from  the  disease  and  collapse  was 
threatened,  the  administration  of  strych- 
nine and  of  inhalations  of  oxygen  pro- 
duced most  remarkable  results  on  two 
occasions.  Gilchrist  (Brit.  Med.  Jour., 
Feb.  13,  '92). 

Literature  of  '96-'97-'98. 

In  cases  seen  early,  especially  those 
presenting  pleurodynia  or  pleuritic  symp- 
toms, the  writer  gives  the  following:  — 

I£  Salol,  3  grains. 

Terpine  hydrate,  3  grains. 
Mix.    In  powder  or  capsule. 


INFLUENZA. 


TREATMENT. 


One  powder  or  capsule  is  given  every 
two,  three,  or  four  hours,  according  to 
the  indications  of  the  case,  and  this 
treatment  is  kept  up  for  from  twenty- 
four  to  thirty-six,  or  even  forty-eight 
hours,  according  to  the  progress  of  the 
symptoms  and  of  lesions,  in  case  the 
pleura  or  lung  be  involved.  In  the  latter 
case  strychnine  sulphate  from  1/100  to  V30 
grain  is  combined  with  it.  If  cough  is 
sufficiently  troublesome  to  require  seda- 
tives, codeine,  from  1/24  grain  to  1/10 
grain,  is  likewise  added.  S.  Solis-Cohen 
(Phila.  Polyclinic,  Apr.  4,  '96). 

Literature  of  '96-'97-'98. 

In  multiple  neuritis  following  influenza 
treatment  should  consist  first  in  absolute 
rest  in  bed.  Anodynes  must  be  given  in 
sufficient  doses  to  relieve  pain,  when  that 
is  a  prominent  symptom.  The  antipyretic 
anodynes  are  insufficient  in  safe  doses  if 
the  patient  has  pains  for  many  days. 
Cinchonidine  salicylate  is  distinctly  valu- 
able. At  a  later  stage  potassium  iodide 
and  mercuric  chloride  in  small  doses  are 
helpful.  When  the  pain  is  seated  in  an 
extremity,  firm  pressure  with  a  flannel 
bandage  yields  great  comfort.  Blisters 
over  the  painful  nerve-trunks  when  they 
are  superficial  are  also  valuable  in  reliev- 
ing pain.  Close  watch  must  be  kept  on 
the  action  of  the  heart  and  the  character 
of  the  breathing.  In  most  of  the  fatal 
cases  death  results  through  paralysis  of 
the  diaphragm.  The  closest  attention 
must  be  given  throughout  the  course  of 
the  case  to  the  nutrition  of  the  patient 
and  to  the  condition  of  the  skin,  espe- 
cially over  portions  of  the  body  exposed 
to  pressure.  As  far  as  possible  the  stom- 
ach should  be  reserved  for  food.  Allyn 
(Jour.  Amer.  Med.  Assoc.,  July  24,  '97). 

A  soldier  was  brought  to  the  hospital 
suffering  with  severe  influenza,  which 
commenced  with  a  violent  chill  and  pain 
in  the  side.  Bacteriological  examination 
of  the  sputum  showed  the  presence  of 
numerous  streptococci.  Marmorek's  se- 
rum injected — 20  cubic  centimetres  (5 
drachms)  each  time — and  after  four  in- 
jections the  temperature  was  reduced  to 
normal.  The  patient  recovered  com- 
pletely. Carrieu  and  Pelan  (La  Med. 
Mod.,  Apr.  27,  '98). 


The  foregoing  outline  of  treatment  of 
influenza  is  the  result  of  my  own  obser- 
vations during  all  the  epidemics  that 
have  prevailed  in  this  country  since  1837. 
The  only  cases  of  threatened  "heart-fail- 
ii  re"  that  have  been  met  with  were  in 
patients  who  were  habitual  drinkers  of 
alcoholic  liquors  or  had  taken  large  doses 
of  some  one  of  the  coal-tar  antipyretics 
with  brandy  or  whisky. 

Antipyrine  is  of  service  in  allaying  the 
spasmodic  cough  of  influenza  associated 
with  bronchial  catarrh  and,  in  some 
cases,  with  subacute  bronchitis.  E.  T. 
Bruen  (University  Med.  Mag.,  Jan.,  '89). 

Subcutaneous  injections  of  pilocarpine 
followed  by  excellent  results.  Pyrexia 
may  be  met  by  cold  sponging,  cold  affu- 
sions, the  cold  pack,  or  the  cold  bath. 
Antipyrine,  antifebrin,  and  kindred 
remedies  largely  used  during  epidemic, 
and  rendered  excellent  service.  Eich- 
horst  (Corres.  f.  Schweizer  Aerzte,  Mar. 
1,  '90). 

In  the  pains  of  influenza  antipyrine  is 
the  analgesic  par  excellence.  H.  Reding 
(Med.  Standard,  Dec,  '90). 

In  the  painful  form  of  influenza  anti- 
pyrine and  exalgin  hold  the  first  place. 
These  failing,  injections  of  morphine 
may  be  made.  In  the  gastro-intestinal 
form,  absolute  rest  in  the  recumbent  post- 
ure should  be  maintained,  and  prepara- 
tions of  opium,  of  which  paregoric  is  the 
best,  administered.  In  the  catarrhal 
form,  quinine,  4  grains,  morning  and 
evening,  should  be  given,  alone  or  com- 
bined with  antipyrine,  15  grains.  Aco- 
nite is  also  useful  in  this  variety.  Stimu- 
lants may  be  required.  Pulmonary  com- 
plications call  for  cardiac  tonic  treat- 
ment:— 

R  Caffeinee, 

Sodii  benzoatis,  of  each,  30  grains. 
Aquas  bullientis,  1  l/s  drachms. 
M.    Sig.:   Fifteen  minims  b.  vel  t.  d., 
subcutaneously. 

If  possible  convalescence  should  be 
spent  in  the  country.  Dujardin-Beau- 
metz  (Bull.  Gen.  de  Ther.,  Jan.  15,  *90). 

Mixture   of   antipyrine   and  salicylic 


INFLUENZA.  TREATMENT. 


47 


acid  of  value,  to  be  followed  by  a  pill 
containing  iron  and  mix  vomica.  Bige- 
low  (Med.  Bull.,  May,  '91). 

Case  in  which  acetanilid  has  been 
given  in  doses  of  25,  15,  and  10  grains, 
respectively,  within  twenty-four  hours, 
with  toxic  effect:  cyanosis,  syncope, 
subnormal  temperature,  and  excitement. 
Childs  (Atlanta  Med.  and  Surg.  Jour., 
Feb.  '91). 

The  depression  following  the  acute  at- 
tack of  the  disease  is,  in  part,  attributed 
to  the  administration  of  large  doses  of 
antipyrine,  phenacetin,  and  antifebrin. 
Patton  (Med.  and  Surg.  Rep.,  May  23, 
'91). 

Salipyrin  has  rendered  excellent  serv- 
ice in  influenza.  Argo  (Ther.  Monats., 
May,  '92). 

Phenacetin  recommended  in  influenza 
in  small  and  frequent  doses.  The  drug 
does  not  cause  gastric  disturbances,  it  is 
prompt  and  decided  in  its  action,  it  has 
no  cumulative  effects,  and  it  is  much 
safer  for  children  and  old  people  than  is 
opium.  P.  0.  Stimson  (Med.  and  Surg. 
Rep.,  Nov.  21,  '91). 

Phenacetin  warmly  recommended  in 
from  4  to  10  grains.  The  second  dose  is 
given  an  hour  after  the  first,  and  re- 
peated every  four  hours  if  the  patient  is 
not  relieved.  Clemow  (Brit.  Med.  Jour., 
June  27,  '91). 

Use  of  antipyrine  advised  in  influenza. 
Salipyrin  and  quinine  also  of  service. 
De  Renzi  (La  Clinica  Moderna,  Dec,  '95). 

Protests  against  reckless  use  of  such 
drugs  as  salicin  and  antipyrine;  relieve 
immediate  symptoms,  but  tedious  con- 
valescence and  cardiac  debility  encour- 
aged. Quinine  the  true  antitoxic  in 
influenza.  Burney  Yeo  (Lancet,  Mar.  2, 
'95). 

Concurrence  with  Burney  Yeo  and  Mof- 
fatt,  but  patient  should  be  alleviated  by 
active  measures.  To  do  this  and  lower 
the  temperature  in  influenza,  4-  to  6-grain 
hourly  doses  (in  cachets)  of  phenacetin 
valuable.  Two  more  cachets  at  intervals 
of  four  hours,  if  necessary.  J.  H.  Bar- 
nard (Lancet,  Mar.  23,  '95). 

Diminished  mortality  and  shortened 
period  of  convalescence  of  recent  epi- 
demics of  influenza  due  to  the  fact  that 
antipyrine  and  similar  depressants  are 


being  withheld.  Grant  (Lancet,  Mar.  2, 
'95). 

Antikamnia  is  one  of  the  best  remedies 
in  influenza.  In  doses  of  3  to  10  grains 
it  appears  to  act  as  a  speedy  and  effective 
antipyretic  and  analgesic.  The  average 
dose  is  only  5  grains,  which  may  be  re- 
peated without  fear  of  unpleasant  symp- 
toms. T.  D.  Crothers  (Quarterly  Jour, 
of  Inebriety,  Jan.,  '94). 

Literature  of  '96-'97-'98. 

Phenacetin  considered  the  safest  and 
best  remedy  in  influenza  in  the  infant. 
As  high  as  5  grains  at  a  dose  has  been 
given  an  infant  eighteen  months  of  age, 
with  no  depression.  It  was  used  in  this 
case  on  account  of  a  threatened  convul- 
sion, which  passed  away,  and  the  child 
quieted  down  and  went  to  sleep.  Gener- 
ally from  Y2  to  2  grains  should  be  given 
to  children,  with  careful  directions  when 
to  stop  it.  B.  M.  Smith  (Ped.,  July  15, 
'97). 

Salipyrin  looked  upon  as  almost  a 
specific  in  influenza  in  childhood.  At 
ages  from  five  to  ten  years  4 1/2  grains 
are  given  thrice  a  day;  from  ten  to  four- 
teen years,  15  grains  thrice  a  day.  After 
a  couple  of  days  it  will  usually  be  suffi- 
cient to  give  only  two  doses  a  day.  Furst 
(Rev.  Mens,  des  Mai.  de  l'Enfance,  Jan., 
'98). 

Antipyrine  is  often  harmful  in  the 
asthenic  forms  of  epidemic  influenza. 
Far  preferable  to  quinine.  L.  Landouzy 
(La  Presse  Med.,  No.  10,  p.  57,  '98). 

Some  of  these  have  required  the  dili- 
gent and  protracted  use  of  strychnine, 
strophanthin,  and  other  vasomotor 
tonics,  with  rest  and  fresh  air,  to  secure 
a  return  to  health. 

Tincture  of  strophanthus,  from  1  to  5 
minims,  with  milk  and  cognac,  recom- 
mended, and  in  grave  cases  inhalations  of 
oxygen  and  subcutaneous  injection  of 
strychnine.  Giovanni  (L'Observatore, 
Torino,  Jan.  25,  '89). 

The  severe  nervous  prostration  re- 
quires alcohol  and  quinine,  and  in  bad 
cases  even  injections  of  caffeine  and 
ether.    In  the  neuralgic  or  rheumatoid 


48 


INFLUENZA. 


INSANITY.  DEFINITION. 


form  of  influenza,  antipyrine,  15  grains, 
combined  with  the  bicarbonate  of  sodium, 
7.5  grains,  is  recommended  every  four 
hours.  Huchard  (Revue  Gen.  de  Clin,  et 
de  Ther.,  Dec.  12,  '89). 

In  the  treatment  of  the  cardiac  compli- 
cations of  influenza  alcohol  is  of  the  first 
importance  in  cases  of  simple  heart-fail- 
ure. Caffeine  citrate  and  cactus  grandi- 
flora  proved  next  in  value.  Nitroglycerin 
appeared  to  act  well  in  the  aged  and  in 
gouty  cases  at  any  period  of  life,  and 
strychnine  was  also  of  great  service. 
Curtin  and  Watson  (Inter.  Med.  Jour., 
Jan.,  '93). 

Convalescence  following  influenza : 
Glycerophosphate  of  lime  in  form  of  wine, 
syrup,  or  capsules;  remarkable  results. 
Lafage  (Le  Bull.  Med.,  Mar.  27,  '95). 

Convalescence  following  influenza : 
Glycerophosphates  of  lime,  iron,  sodium, 
magnesium,  and  potassium,  either  by  sub- 
cutaneous injection  or  by  the  mouth. 
Albert  Robin  (Bull.  Gen.  de  Ther.,  May 
15,  30,  '95). 

Literature  of  '96-'97-'98. 

Strychnine  arsenate  or  strychnine  sul- 
phate (1/128  grain)  every  hour  or  two,  not 
more  than  eight  or  ten  doses  being  given 
daily,  admirably  supports  the  nervous 
system,  and  therefore  the  heart.  Edi- 
torial (Indian  Lancet,  May  16,  '97). 

Nathan  S.  Davis, 

Chicago. 

INGROWING  TOE-NAIL.  See  Nails, 
Diseases  of. 

INSANITY. 

Definition. — Insanity  means  disordered 
mental  function. 

All  disordered  mental  function  is, 
however,  not  insanity;  for  example,  the 
delirium  of  fever,  of  alcoholic  or  drug 
intoxication,  although  disordered  mental 
function,  is  not,  strictly  speaking,  in- 
sanity; still,  the  physical  disorder  upon 
which  the  febrile  or  toxic  delirium  de-  I 
pends  does  not  differ  so  much  from  the  | 


underlying  physical  condition  of  insanity 
as  may  at  first  thought  appear.  The  dis- 
order of  function  in  all  cases  is  primarily 
due  to  a  derangement  of  nutrition  in  the 
brain.  This  brings  us  to  the  funda- 
mental fact  that  in  order  to  have  dis- 
ordered function  of  the  brain  we  must 
have  either  disordered  nutrition  or 
structural  alteration  of  this  organ. 

At  the  present  day  this  apparently  ma- 
terialistic conception  must  be  accepted. 
As  no  mental  or  psychical  manifestations 
can  occur  except  through  the  medium  of 
the  brain,  we  may  say  outright  that  the 
brain  is  the  organ  of  the  mind,  and  any 
alteration  in  the  structure  or  nutrition  of 
the  brain  will  affect  favorably  or  un- 
favorably the  functions  of  that  organ. 
Upon  this  basis  we  may  assume  that 
without  brain  there  can  be  no  thought; 
and  without  healthy  brain  there  can  be 
no  healthy  thought. 

The  morbid  physical  basis  of  insanity 
is  disordered  nutrition  of  the  brain  in 
differing  stages.   It  may  be: — 

1.  Anaemia. 

2.  Hyperemia. 

3.  Inflammation  of  the  brain  or  me- 
ninges. 

4.  Toxic  substances  circulating  in  the 
blood  (drug  or  bacterial  poisons). 

5.  Gross  lesions  of  brain-structure, 
such  as  tumors,  apoplexies,  abscesses, 
embolism  with  consecutive  softening. 
These  may  be  results  of  nutritive  dis- 
turbances. 

6.  Interstitial  hyperplasia  of  connect- 
ive tissue,  which  is  probably  primarily  in- 
flammatory. • 

7.  Primary  structural  alteration,  he- 
reditary or  acquired. 

Insanity  must  be  conceived  as  a  phys- 
ical disease, — a  disease  of  the  brain. 
While  it  is  customary  to  speak  of  mental 
disease,  or  of  a  psychosis,  it  is  well  under- 
stood that  a  disorder  of  the  mind — or 


INSANITY.  CLASSIFICATION. 


49 


psyche — having  no  relation  to  a  physical 
substratum,  the  brain,  is  impossible. 

Classification.  —  Basing  mental  dis- 
ease upon  these  physical  substrata,  the 
usual  symptomatic  classification  of  in- 
sanity into  mania,  melancholia,  and  de- 
mentia appears  about  as  rational  as  a 
division  of  kidney  diseases  into  polyuria, 
anuria,  and  incontinence. 

The  first  requisite  for  a  logical  study 
of  insanity  is,  therefore,  a  rational  classi- 
fication,— one  based  upon  the  known 
pathology  or  pathogeny  of  the  disease. 
The  time  for  a  perfect  classification  of 
this  sort  has  not  yet  arrived;  our  knowl- 
edge is  still  too  vague  or  incomplete;  but 
in  the  following  an  attempt  has  been 
made  which  may  have  some  merits  as  a 
working  scheme. 

In  this  classification  there  are  seven 
classes  or  groups  of  mental  disturbance, 
most  of  them  clearly  differentiated  clin- 
ically, but  all  based  upon  pathology  or 
pathogeny. 

The  groups  are  as  follow: — 

I.  Psychoses  due  to  imperfect  develop- 
ment of  the  brain,  which  may  be  heredi- 
tary, congenital,  or  acquired.  To  this 
group  belong  idiocy  and  imbecility. 

II.  Psychoses  due  to  vicious  or  abnor- 
mal brain-organization.  These  are  al- 
ways hereditary.  To  this  group  belong 
paranoia,  circular  and  recurrent  insanity. 
Some  cases  of  hysteria  and  epilepsy  may 
also  be  included. 

Literature  of  '96-'97-'98. 

Causes  of  insanity  investigated  in  the 
last  1014  patients  admitted  to  the  Bris- 
tol Lunatic  Asylum,  507  being  males  and 
a  like  number  females. 

From  the  statistics  obtained  it  would 
appear  that  all  forms  of  insanity  are 
strongly  hereditary,  the  percentage  being 
for  all  cases  with  a  definite  history  of 
hereditary  predisposition  28.7  per  cent., 
and  with  a  strongly  neurotic  history  4.1 
per  cent.:   total,  32.8  per  cent. 


That  of  all  forms  the  congenital  hold 
the  first  place  with  44.4  per  cent. 
Puerperal  insanity  seems  to  be  the  next 
most  hereditary  form,  with  33.3  per  cent, 
hereditary  predisposition,  and  7  per  cent, 
with  neurotic  history,  these  percentages 
having  regard  to  female  cases  only. 
Then  follow  the  ordinary  cases,  with 
29.7  hereditarily  predisposed  and  4.9 
with  a  history  of  neurosis;  23  per  cent, 
in  general  paralysis,  21.5  per  cent,  in 
epilepsy.  J.  R.  Blachford  (Jour,  of  Men- 
tal Science,  July,  '98). 

The  simulated  paranoia  of  chronic 
alcoholism  belongs  to  a  different  group 
(Group  VI). 

III.  Psychoses  due  to  simple  disturb- 
ance of  nutrition  in  the  brain,  such  as 
anaemia  and  hyperemia.  To  this  group 
belong  the  majority  of  cases  of  melan- 
cholia (depression)  and  mania  (exalta- 
tion). In  many  cases  the  diagnosis 
"melancholia"  and  "mania"  are  incor- 
rect, a  transitory  depression  or  exaltation 
being  regarded  as  the  essential  clinical 
manifestation. 

IV.  Psychoses  due  to  microscopical 
structural  alterations  in  the  brain.  These 
are  primarily  probably  nutritional  or 
toxic. 

In  this  class  are  included  general  pare- 
sis, catatonia,  consecutive  dementia, 
senile  dementia,  and  epileptic  dementia. 

In  a  majority  of  the  brains  of  those 
dying  insane,  macroscopical  examination 
shows  a  milky  opacity  of  the  arachno- 
pia,  closely  associated  with  underlying 
morbid  processes  in  a  space  which  can 
be  covered  with  the  two  hands  placed  to- 
gether, the  lower  ends  of  the  hypothenar 
eminences  covering  the  spot  where  the 
fissures  of  Rolando  meet.  The  giant 
pyramids  are  the  first  to  show  markedly- 
filtered  structure.  J.  B.  Tuke  (Edin- 
burgh Med.  Jour.,  Feb.  to  June,  '94). 

The  doctrine  of  the  neuron  and  the 
interrelation  of  neurons  within  the  cen- 
tral nervous  system  affords  a  foundation 
for  possibilities  in  nerve-activity.  The 
cortical  areas  are  themselves  complex 


INSANITY.  CLASSIFICATION. 


structures,  yet  in  each  cluster  the  indi- 
vidual neuron  preserves  not  only  its  in- 
tegrity as  distinct  from  other  neurons, 
but  also  its  threefold  character  as  a 
nutritive  and  dynamic  doubly-connected 
apparatus.  The  human  brain  shows  four 
layers:  (1)  the  molecular  layer;  (2) 
the  ambiguous  layer;  (3)  long  pyram- 
idal layer;  (4)  mixed  pyramidal  or 
polymorphic  layer,  including  Meynert's 
layer,  plus  spindle  layers.  Alteration 
and  destruction  of  fine  naked  collaterals 
and  nerve-terminals  shown  to  exist  in  the 
molecular  layer  and  swelling  and  soften- 
ing of  minute  protoplasm-granules  at- 
tached to  special  processes  in  the  super- 
ficial layer  of  the  cortex.  Lloyd  Andrie- 
zen  (Brain,  P.  68,  p.  549,  '95). 

Possibility  of  there  being  no  non- 
medullated  nerve-fibers  in  the  cerebral 
cortex.  Naked  axis-cylinders  ought  to 
be  a  physiological  impossibility  in  cere- 
brum ;  their  presence  could  only  give  rise 
to  irregular  overflow  of  energy,  with 
corresponding  confusion.  It  is  probably 
through  protoplasmic  processes  in  lateral 
buds  or  gemmules  that  the  axons  influ- 
ence protoplasm  of  dendrons  and  cells. 
Their  uncovered  endings  come  into 
close  contiguity  with  gemmules.  The 
gemmules  that  are  specially  liable  to  in- 
jury from  toxic  or  morbid  influences  are 
the  first  portions  of  the  neuron  to 
atrophy  and  disappear  in  certain  dis- 
eases. H.  J.  Berkley  (Medical  News, 
Nov.  9,  '95). 

Changes  as  given  by  Lloyd  Andriezen 
explain  the  diminished  sensitiveness  of 
an  alcoholic  subject  to  impressions  from 
without,  and  also  the  general  loss  of 
memory  and  lack  of  association  of  ideas. 
Microscopical  examination  cannot  give 
us  all  the  information  we  desire  when 
the  initial  cause  is  not  known.  The  con- 
viction is  steadily  growing  that  actual 
agents  which  produce  tissue-changes  are 
chemico-toxic,  absorbed  or  ingested,  pro- 
duced by  altered  tissue-metabolism  or 
elaborated  by  bacteria.  Dercum  (Jour. 
Amer.  Med.  Assoc.,  July  15,  '95). 

Literature  of  '96-'9?-'98. 

The  presence  of  micro-organisms  in  the 
cerebro-spinal  fluid  and  cortex  involve 
their  pre-existence  in  some  other  part  of 


the  organism,  and  their  presence  during 
the  course  of  acute  mental  disturbances 
is  not  relational  or  causative,  but  associ- 
ative. H.  A.  Tomlinson  (Northwestern 
Lancet,  Sept.  1,  '97). 

V.  Psychoses  due  to  gross  lesions  in 
the  brain.  To  this  class  belong  syphilitic 
insanity,  post-apoplectic  insanity,  in- 
sanity from  tumors  and  abscesses,  and  in- 
sanity from  cranial  traumatisms. 

VI.  Psychoses  due  to  toxic  substances 
circulating  in  the  brain.  In  this  class  are 
included  acute  confusional  insanity, 
puerperal  insanity;  alcoholic,  plumbic, 
and  other  chronic  drug  intoxications; 
uramiic  insanity,  post-febrile  and  most 
cases  of  post-operative  insanity,  and  in- 
solational  insanity. 

A  form  of  insanity  combined  with 
multiple  neuritis  is  the  result  of  blood- 
poisoning,  which  affects  the  whole  nerv- 
ous system,  especially  the  peripheral 
nerves.  Ireland  (Jour,  of  Mental  Sci- 
ence, July,  '90). 

Specific  infection  must  be  included 
among  the  causes  of  mental  symptom*. 
Analogies  with  nervous  affections  known 
to  be  of  microbic  origin  favor  the  view 
that  insanities  witli  similar  or  related 
phenomena  or  lesions  are  also  microbic 
in  origin.  Mental  disorders  of  pregnancy 
and  puerperal  state  are  probably  in  a 
considerable  portion  of  cases  toxaemic. 
C.  K.  Mills  (Amer.  Jour.  Med.  Sci.,  Nov., 
'94). 

It  is  of  comparatively  rare  occurrence 
for  actual  insanity  to  develop  during 
course  of  bodily  disease.  When  the 
cause  is  not  continuous. —  such  as 
poisons,  fevers,  and  traumata. — mental 
symptoms,  in  the  great  majority  of  cases, 
disappear;  in  heart  disease  and  phthisis 
they  may  disappear  and  reappear  from 
time  to  time;  iii  some  cases,  such  as  in- 
sanity connected  with  gouty  kidney,  they 
only  disappear  with  death.  Reynolds 
(Brit.  Med.  Jour.,  Sept.  2S.  '95). 

Literature  of  '96-'97-'98. 

Tuberculosis  is  not  believed  to  be  a 
cause  of  insanity,  but  the  results  of 
tuberculosis  in  any  of  their  forms — in 


INSANITY.    CLASSIFICATION.  SYMPTOMS. 


51 


other  words,  tuberculous  dyscrasia  of 
any  kind — is,  just  as  any  other  dys- 
crasia, one  of  the  causes  of  disease  of  the 
mind,  or  insanity.  Ales  Hrdlicka  (Al 
Shifa,  Jan.,  '96). 

Conclusions  as  to  the  possible  relation 
of  intestinal  autointoxication  to  mental 
disturbance:  1.  Urines  rich  in  indican 
contain  very  little  or  no  preformed  sul- 
phuric acid,  and  are  toxic.  2.  When  the 
sulphate  ratio  is  materially  changed,  it 
is  likely  to  indicate  autotoxis  in  connec- 
tion with  an  increase  in  the  amount  of 
combined  or  ethereal  sulphates.  3. 
Such  indications  are  generally  found 
with  acute  insanities,  in  which  rapidly 
developing  symptoms  occur.  4.  Fuga- 
cious and  changing  illusions  and  hallu- 
cinations, unsystematized  delusions,  con- 
fusion, and  verbigeration  in  connection 
with  insomnia,  pallor,  intestinal  indiges- 
tion, constipation,  and  rapid  exhaustion, 
are  due  to  autotoxis.  5.  Paranoiac 
states,  or  those  in  which  concepts  are 
the  features;  chronic  stuporous  condi- 
tions, and  certain  forms  of  dementia 
have  little  to  do  with  the  formation  of 
intestinal  products  of  putrefaction.  6. 
Various  post-febrile,  traumatic,  alcoholic, 
or  drug  insanities  are  those  in  which 
autotoxis  is  most  constant.  7.  The  vari- 
ations in  the  excretion  of  combined  sul- 
phates keep  pace  with  the  changes  in 
the  progress  of  an  established  insanity, 
acnes  and  epileptoid  attacks  being  di- 
rectly connected  with  the  putrefactive 
processes.  8.  The  most  successful  treat- 
ment consists  in  lavage;  intestinal 
douches;  gastric  and  intestinal  antisep- 
sis by  means  of  hydrochloric  acid,  borax, 
sodium  salicylate,  charcoal,  guaiacol,  or 
naphthalin  in  small,  repeated  doses;  and 
the  administration  of  a  combination  of 
the  red  marrow  from  the  small  bones, 
blood,  and  glycerin.  A.  McL.  Hamilton 
(N.  Y.  Med.  Jour.,  Nov.  14,  '96). 
VII.  Psychoses  clue  to  developmental 
changes  in  the  brain,  nutritive  or  struct- 
ural. In  this  class  are  placed  pubescent 
and  climacteric  insanity.  It  may  be 
questioned  whether  these  forms  of  in- 
sanity are  due  to  developmental  changes 
in  the  brain,  but  the  general  similarity 
in  character  of  the  symptoms  coincident 


with  the  period  of  puberty  or  of  the 
menopause  justifies  the  assumption  of 
such  changes,  even  in  the  absence  of  di- 
rect demonstration. 

Symptoms. — The  symptoms  of  in- 
sanity may  be  divided  into  physical  and 
psychical  or  mental.  The  former  are 
referable  to  the  circulatory,  digestive, 
secretory,  genito-urinary,  and  nervous 
systems.  The  general  nutrition  of  the 
I  body  is  frequently  defective.  Chapin 
states  that  "90  per  cent,  of  the  admis- 
sions to  the  hospitals  present  the  condi- 
tion and  appearance  of  some  form  of 
bodily  ill-health." 

The  source  of  mental  diseases  is  not 
only  in  the  brain  itself,  but  in  all  the 
organs.  For  this  reason  no  pathological 
changes  are  found  in  the  brain  in  many 
mental  diseases,  and  when,  with  time, 
they  do  appear,  they  are  consecutive,  but 
not  primary.  In  examining  and  diag- 
nosing the  psychical  condition  of  a  man, 
one  must  closely  and  minutely  examine 
the  whole  organism,  and  not  omit  any 
change  in  any  organ,  though  seemingly 
insignificant,  since  experience  teaches 
that  very  serious  changes  in  the  func- 
tion of  the  brain  arise  from  insignificant 
changes  either  in  the  nerves  or  in  other 
organs.  Ladislas  Kohlberger  (Przeglad 
Lekarski,  Nos.  25  and  26,  '93). 

Anaemia  is  extremely  frequent,  espe- 
cially in  states  of  depression  and  mental 
confusion.  In  the  large  majority  of  cases 
of  acute  insanity  careful  inquiry  will  de- 
velop the  fact  that  preceding  the  attack 
there  was  progressive  loss  of  weight. 

Depression  of  the  circulation,  weak- 
ened heart-action,  and  an  apparent  lack 
of  vascular  tonus  are  frequent.  They 
are  most  notable  in  melancholia,  general 
paresis,  and  consecutive  dementia.  Vas- 
omotor spasm  is  often  present  in  par- 
anoia, combined  with  oppression  of 
breathing,  and  a  sense  of  great  anxiety. 

In  a  study  of  the  blood  in  the  insane 
the  haemoglobin  percentage  was  always 
below  normal.    In  melancholia  this  per- 


INSANITY. 


SYMPTOMS. 


centage  averaged  69.7;  in  epilepsy, 
62.92;  in  general  paralysis,  68.75;  and 
in  secondary  dementia,  53.75. 

The  most  marked  diminution  in  the 
number  of  red  corpuscles  occurred  in  the 
cases  of  dementia,  the  average  being 
4,070,000  per  cubic  millimetre.  The  next 
in  order  were  the  epileptics,  who  pre- 
sented a  corpuscular  strength  of  4,520,- 
800.  The  cases  of  general  paralysis  gave 
a  count  of  4,700,250.  W.  Johnson  Smith 
(Jour,  of  Mental  Sci.,  Oct.,  '90). 

Examination  of  fourteen  cases  with 
reference  to  leucocytes.  In  cases  of  se- 
nile dementia  there  is  an  increase;  in 
general  paralysis,  marked  decrease;  in 
cases  with  tendency  to  maniacal  excite- 
ment, great  increase.  Burton  (Amer. 
Jour,  of  Insanity,  Apr.,  '95). 

Toxicity  of  blood-serum,  in  cases  of 
mental  disease,  found  to  be  as  follows: 
In  paranoia  it  resembles  most  nearly  the 
normal;  in  lypemania  it  is  less  toxic; 
in  dementia  it  is  always  diminished;  in 
general  paresis  it  is  increased,  as  also  in 
acute  mania.  In  epilepsy,  imbecility, 
idiocy,  and  "moral  insanity"  the  toxicity 
is  normal  or  diminished.  D'Abundo 
(Jour,  de  Med.,  Feb.  12,  '93). 

Death  of  a  rabbit  induced  by  the  in- 
travenous injection  of  15  minims  of 
serum  from  a  healthy  man  per  3  i/4 
ounces  of  the  animal's  weight.  The  toxic 
action  of  the  serum  of  the  insane  was 
augmented  when  the  state  of  excitation 
existed,  and  diminished  when  the  con- 
dition was  one  of  depression,  dementia, 
or  idiocy.  Rummo  and  Bordini  ("Rev. 
Sper.  di  Fren.  e  di  Med.  Legale  in  Rela- 
zione  con  l'Antrop.  e  le  Sci.  Giur.  e  Soc," 
Reggio-Emilia,  '93). 

The  wide-spread  degeneration  of  the 
arterial  system,  commonly  found  in  the 
insane,  plays  a  very  important  part  in 
the  pathogenesis  of  mental  aberration. 
Beadles  (Jour,  of  Mental  Science,  Jan., 
'95). 

In  clearly  established  cases  of  insanity 
there  is  a  considerable  increase  in  the 
average  frequency  of  the  pulse,  both 
among  men  and  among  women.  Aver- 
age from  2172  cases,  84.8  in  women  and 
80.8  in  men.  Abnormal  tracings  arc 
found  at  sonic  stage  of  the  disease  in  a 


vast  majority  of  cases.  Th.  H.  Kellogg 
(N.  Y.  Med.  Jour.,  July  6,  '95). 

Examination  of  the  post-mortem  rec- 
ords of  the  Dalldorf  Asylum  in  Berlin. 
Heart-lesions  found  present  in  males  in 
61.67  per  cent,  and  in  females  in  42.75 
per  cent.  In  the  sane,  according  to  the 
records  of  the  Erlangen  Pathological 
Institute,  the  proportion  of  heart-lesions 
is  27  per  cent,  for  males  and  23.2  per 
cent,  for  females.  Valvular  lesions  are 
most  frequent.  C.  Strecker  (Schmidt's 
Jahrbiicher,  Sept.  15,  '94). 

Literature  of  '96-'97-'98. 

Diseases  of  the  heart  may  become  the 
exciting  cause  of  the  insanity  in  predis- 
posed persons.  The  different  symptoms 
which  accompany  such  disorders,  such  as 
pain  in  the  precordial  region,  palpita- 
tion, exaggerated  heart-sounds,  feelings 
of  constriction,  difficulty  of  breathing, 
headache,  and  giddiness,  may  all,  by 
causing  derangements  of  sensation  and 
illusions  of  the  senses,  become  the  start- 
ing-points of  insanity. 

Deficiencies  of  the  heart's  action  may 
lead  to  mental  affections  in  persons  not 
predisposed,  partly  by  deranging  the  cir- 
culation of  blood  in  the  brain,  and  partly 
by  altering  the  chemical  action  of  the 
blood.  The  mental  disorders  thus  caused 
generally  take  the  form  of  mania  hal- 
lucinatoria;  confusional  insanity,  with 
hallucinations.  The  hallucinations  take 
their  color  from  the  abnormal  organic 
feelings. 

If  the  heart  disease  goes  on  without 
alleviation  or  betterment,  the  halluci- 
natory derangement  may  pass  into  de- 
mentia. Jacob  Fischer  (Allge.  Zeit.  f. 
Psych.,  B.  54,  H.  6,  '98). 

Fever  is  not  rare  in  acute  states.  It  is 
most  frequent  in  states  of  mental  con- 
fusion and  exaltation,  but  may  also  be 
preseut  in  depressive  states.  Fever  is 
usually  a  symptom  of  grave  significance 
and  should  always  lead  to  a  careful  phys- 
ical examination.  It  may  signify  a  men- 
ingitis, a  visceral  inflammation,  or  an 
essential  fever. 


INSANITY. 

Observations  on  the  daily  oscillations 
of  temperature  in  functional  psychoses. 
In  passive  melancholia  the  temperature 
is  generally  diminished.  The  evening 
rise  is  not  very  pronounced.  The  same 
is  true  of  agitated  melancholia.  In 
mania  there  is  a  rise  of  4.5°  to  9°  F.  dur- 
ing the  height  of  the  disease.  In  para- 
noia the  temperature-curve  is  normal. 
In  stupor  it  is  below  normal.  Hysterical 
psychoses  show  irregular  oscillations. 
In  general  paresis  and  dementia  the  tem- 
perature is  sometimes  much  below  nor- 
mal. Th.  Ziehen  (Deut.  med.-Zeit.,  Aug. 
23,  '94). 

Among  the  prominent  symptoms  ref- 
erable to  the  digestive  system  is  ano- 
rexia, often  leading  to  absolute  refusal  of 
food.  This  is  frequently  due  to  gastro- 
intestinal disorders,  but  in  many  cases 
the  refusal  of  food  is  the  consequence  of 
hallucinations  or  delusions.  The  patient 
has  a  fear  of  food  (sitiophobia),  either 
because  he  thinks  the  food  will  not  be 
digested,  or  that  there  is  obstruction  of 
the  bowels,  or  total  absence  or  decay  of 
the  abdominal  viscera,  or  because  he  is 
afraid  of  being  poisoned.  The  fear  of 
poisoning,  due  to  hallucinations  of  taste 
is  a  frequent  symptom  of  paranoia.  De- 
lusions of  obstruction  or  absence  of  ab- 
dominal viscera  are  often  present  in 
melancholia.  Want  of  appetite  is  also 
sometimes  an  expression  of  the  extreme 
indifference  to  all  subjective  sensations 
or  objective  impressions  in  advanced  de- 
mentia. 

In  maniacal  states  there  is  often  an 
abnormal  desire  for  food.  This  may  al- 
ternate with  absolute  anorexia. 

Of  169  cases  of  visceral  diseases,  87 
suffered  at  one  time  or  another  from  re- 
ferred pain  associated  with  superficial 
tenderness.  Mental  disturbance  seemed 
to  stand  in  direct  relation  to  the  in- 
tensity of  pain.  Depression  seemed  to.be 
associated  mainly  with  the  presence  of 
areas  over  lower  part  of  chest  and  over 
the  abdomen.  Hallucinations  are  only 
present    where    scalp-tenderness    is  a 


SYMPTOMS.  53 

marked  feature  of  the  sensory  disturb- 
ance. Henry  Head  (Brit.  Med.  Jour., 
Sept.  28,  '95). 

Gall-stones  found  to  be  twice  as  fre- 
quent in  the  insane  as  they  are  stated 
to  be  in  the  sane.  Snell  (Brit.  Med. 
Jour.,  Aug.  12,  19,  '93). 

Literature  of  '96-'97-'98. 

Malignant  disease  is  a  well-recognized 
cause  of  refusal  of  food  by  an  insane  pa- 
tient, but  less  attention  appears  to  have 
been  given  to  gastritis,  a  common  dis- 
order among  the  sane,  and  assuredly 
more  so  among  the  insane.  Gastritis  ap- 
pears in  some  cases  to  be  the  most  prob- 
able cause  of  food-refusal.  Many  of 
these  cases  would,  no  doubt,  recover  by 
simple  feeding,  but,  even  in  these,  lavage 
before  feeding  would  probably  hasten  re- 
covery. H.  Harold  Greenwood  (Jour. 
Mental  Science,  Jan.,  '98). 

Persistent  constipation  is  frequent  in 
melancholia.  Diarrhoea  is  comparatively 
rare.  In  many  acute  forms  of  mania 
and  melancholia,  and  in  the  early  stages 
of  general  paresis,  the  patient  passes 
faeces  into  his  clothing  or  the  bed.  This 
is  not  always  due  to  loss  of  control  of  the 
sphincters,  but  is  sometimes  intentional. 
In  advanced  dementia,  paretic  or  con- 
secutive, the  loss  of  sphincteric  control 
is  usually  paralytic. 

The  perspiratory  secretion  is  usually 
diminished  in  melancholia.  In  mania 
salivation  is  often  present. 

Manifestations  on  the  part  of  the 
genito-urinary  system  are  frequent  in  in- 
sanity. In  maniacal  conditions  there  is 
sometimes  polyuria.  Incontinence  is  fre- 
quent in  acute  mania  and  in  dementia. 
Involuntary  passage  of  urine  often  occurs 
during  epileptic  attacks.  Sometimes 
the  urine  is  retained  owing  to  indiffer- 
ence, while  its  retention  may  be  due  to  a 
delusion,  as  in  the  case  of  a  doctor  men- 
tioned by  Chapin,  who  retained  his  urine 
day  after  day  "lest  its  discharge  might 
endanger  the  building  and  human  life." 


54  INSANITY. 

Results  of  inquiry  into  the  relations 
of  acetone,  sugar,  and  albumin  in  the 
urine  of  insane  patients  suffering  from 
diarrhoea  due  to  degeneration  of  the 
solar  plexus.  In  ordinary  intestinal 
catarrh  none  of  the  above  are  present; 
but  in  diarrhoea  due  to  degeneration  of 
the  solar  plexus  sometimes  sugar,  some- 
times albumin,  and  sometimes  both  were 
found.  This  may  aid  in  diagnosis  in 
some  cases.  Cristiani  (Jour,  de  Med., 
Feb.  12,  '93). 

In  1700  cases  albumin  with  renal  tube- 
casts  detected  in  urine  of  more  than  one- 
half  of  the  cases  of  chronic  insanity;  25 
per  cent,  presented  clinical  evidences  suf- 
ficient to  enable  any  competent  practi- 
tioner to  make  a  diagnosis  of  kidney  dis- 
ease. In  75  per  cent,  of  200  cases  the 
kidneys,  examined  post-mortem,  showed 
pathological  changes.  Bondurant  (Amer. 
Jour,  of  Insanity,  July,  '95). 

Of  150  post-mortem  examinations  in 
insanity,  106  cases  of  chronic  renal  dis- 
ease, or  70.6  per  cent.,  found.  Beadles 
(Jour.  Mental  Science,  Jan.,  '95). 

Of  154  post-mortem  cases  of  insanity, 
74  of  renal  disease,  or  48  per  cent.,  found, 
C.  H.  Bond  (Brit.  Med.  Jour.,  Mar.  2, 
'95). 

Of  532  post-mortems  in  cases,  of  in- 
sanity, 327  cases  of  chronic  renal  disease, 
or  61.466  per  cent.,  found.  Bristowe 
(Brit.  Med.  Jour.,  Mar.  2,  '95). 

Exaggerated  sexual  desire  is  frequent 
in  mania,  and  the  early  stages  of  general 
paresis,  leading  to  venereal  excesses,  but 
oftener  to  masturbation.  The  most 
shameless  acts  of  exposure  and  solicita- 
tion are  seen  in  females,  although  mas- 
turbation is  probably  more  frequent  in 
males.  In  depressive  states,  and  in  the 
advanced  stages  of  general  paresis,  sexual 
desire  and  power  are  diminished.  Desire 
sometimes  persists  when  potency  is  ab- 
sent. 

Sexual  perversion  is  a  symptom  that 
may  accompany  any  neurosis  or  psycho- 
sis, and  should  not  be  .considered  as  a 
distinct  affection,  but  as  a  part  of  the 
general  symptomatology  of  insanity. 
Behr  (St.  Petersburger  mod.  Woch.,  Apr. 
4,  '92). 


SYMPTOMS. 

In  acute  psychoses  menstruation  is 
nearly  always  arrested.  It  is  said  that 
one  of  the  earliest  signs  of  improvement 
in  acute  insanity  in  women  is  a  return  of 
the  menstrual  flow. 

Conclusions  based  on  a  study  of  the 
menstrual  function  in  the  insane:  — 

I.  There  is  no  entirely  regular  men- 
strual history,  if  a  number  of  years  be 
taken  into  account,  and  that  periods 
falling  in  from  between  three  and  five 
weeks  are  to  be  considered  normal. 

II.  Normal  menstruation  is  an  expres- 
sion of  the  general  condition,  and  its 
suppression  is  often  only  an  indication 
of  the  needs  of  the  system,  and  so  is  a 
conservative  act  of  nature. 

III.  In  the  chronic  insane  the  meno- 
pause makes  no  radical  change  in  the 
form  of  disease. 

IV.  In  acute  cases  menstruation  re- 
turns with  regained  general  health,  and 
is  an  indication  that  the  system  can 
again  sustain  the  loss  of  force.  It  is 
always  to  be  regretted  when  there  is  not, 
at  the  same  time,  increased  mental  vigor. 

V.  Tonics  and  general  measures  are, 
as  a  rule,  preferable  to  direct  or  local 
treatment,  though  sometimes  both  are 
valuable. 

VI.  The  underlying  conditions  which 
cause  irregularities  of  menstruation  are 
oftener  the  cause  of  mental  disease  than 
those  deviations  per  se.  Bissell  (North- 
western Lancet,  Apr.  15,  '92). 

Of  99  cases  of  chronic  insanity,  men- 
struation, on  the  whole,  regular;  ir- 
regularity occurred  in  patients  generally 
over  35.  Climacteric  appeared,  on  the 
whole,  earlier.  Menstruation  had  influ- 
ence almost  certainly  in  16  or  18  cases, 
questionably  in  18.  Erotism  rare.  Men- 
strual period  seems  to  exert  an  actual 
influence,  principally  when  the  pain 
arising  from  some  genital  trouble  reacts 
on  the  system.  Naecke  ("Influence  of 
Menstruation  on  Chronic  Psychoses," 
'95). 

Literature  of  'Q6-'97-'d$. 

The  menstrual  function  in  the  insane 
d i Gfers  in  no  essential  respect  from  the 
same  process  in  healthy  women,  and  its 
influence  upon  the  psychical  condition  is 


INSANITY. 

slight  and  variable.  Nache  (Archiv  f. 
Psychiatrie,  Feb.  18,  '98). 

Among  the  nervous  phenomena  of  in- 
sanity the  most  frequent  is  insomnia. 
This  is  sometimes  very  persistent  in 
mania  and  general  paresis.  In  the  latter 
and  in  confusional  states  it  rapidly  leads 
to  exhaustion.  An  occasional  symptom 
of  general  paresis  is  a  great  tendency  to 
sleep. 

Headache  is  a  symptom  in  general 
paresis,  cerebral  syphilis,  and  in  melan- 
cholia. In  the  latter  occipital  cephal- 
algia is  said  by  some  observers  to  be  diag- 
nostic. Headache,  more  or  less  intense, 
also  attends  most  cases  of  mental  dis- 
turbance depending  upon  gross  lesions  in 
the  brain. 

Convulsions  are  present  in  epilepsy, 
uraemic  insanity,  general  paresis,  and 
syphilitic  insanity.  The  convulsions  in 
general  paresis  and  syphilitic  insanity 
are  not  typical  epileptic  seizures,  but  of 
the  character  described  as  epileptiform. 
They  also  occur  at  times  in  alcoholic  in- 
sanity. The  epileptiform  attacks  of  gen- 
eral paresis  are  usually  followed  by  a 
comatose  or  paralytic  state  lasting  several 
hours  or  days.  In  some  cases  Cheyne- 
Stokes  respiration  may  be  present  and 
still  the  patient  recover  from  the  attack. 
These  apoplectiform  seizures  also  follow 
true  epileptic  convulsions  at  times. 

Fixed  and  irregular  pupils  or  irregu- 
larity in  the  pupillary  reaction  is  frequent 
in  general  paresis. 

Tremor  is  present  in  alcoholic  insanity 
and  in  certain  forms  of  mental  disturb- 
ance complicating  cerebro-spinal  dis- 
eases. The  fibrillary  tremor  of  the 
tongue  and  facial  muscles  in  general 
paresis  is  diagnostic  in  many  cases. 

The  tendon  -  reflexes  are  affected 
(usually  diminished)  in  general  paresis, 
alcoholic  insanity,  and  the  mental  dis- 
turbances of  peripheral  neuritis.  In 


SYMPTOMS.  55 

some  forms  of  melancholia  the  knee-jerk 
is  increased. 

The  speech  is  early  affected  in  general 
paresis.  The  scanning  speech  of  the 
paretic  is  characteristic.  In  dementia 
the  speech  is  often  indistinct  or  slurring. 

Certain  trophic  disturbances  may  also 
be  looked  upon  as  physical  symptoms  of 
insanity.  Thus,  the  peculiar  deformity 
of  the  ear  termed  "othematoma,"  or  "the 
insane  ear,"  is  almost  limited  to  insane 
persons. 

Bilateral  haematoma  of  the  lobule  may 
occur  as  the  result  of  traction  (violence) 
on  these  parts.  (Archives  of  Otology, 
July,  '94.) 

There  is  strong  evidence  in  favor  of 
the  contention  that  the  proclivity  of  the 
insane  to  othematoma  is  due  to  a  pe- 
culiar degeneration  in  the  cartilage  of 
the  ear.  This  change  is  brought  about 
by  the  same  abnormal  nutritional  state 
which  induces  lesions  of  scalp,  skull,  and 
dura  mater,  to  which  the  insane  are  spe- 
cially prone.  Middlemass  and  Robinson 
(Edinburgh  Med.  Jour.,  Dec,  '94). 

Comparative  study  of  200  sane  and  200 
insane  men  in  reference  to  the  develop- 
ment of  the  mammary  gland,  in  which  it 
is  shown  that  hypertrophy  of  this  organ 
(gynecomastia)  is  from  seven  to  eight 
times  more  frequent  in  the  insane. 
Canger  (Revue  Inter,  de  Bibliog.,  Apr. 
25,  '93). 

Absence  of  overlapping  of  the  anterior 
portion  of  the  upper  dental  arcades  over 
the  lower  is  a  stigma  of  degeneration. 
Camuset  (Annales  Medico-psychol.,  Nov., 
'94). 

In  considerable  number  of  insane 
women  asymmetrical  conditions  of  bi- 
laterally-associated muscles  observed, 
especially  of  the  face. 

In  411  insane  females,  excluding  gen- 
eral paralytics,  inequality  of  pupils  was 
found  in  25  per  cent.  In  396  chronic 
cases,  except  general  paralytics,  35  per 
cent,  had  inequality  of  pupils.  In  306 
recent  cases  the  tongue,  when  protruded, 
was  deflected  from  the  middle  line  in  24 
per  cent.  In  a  number  of  cases  the 
muscles  of  expression  were  more  or  less 


5G 


INSANITY.  SYMPTOMS. 


INSANITY. 

paralyzed  on  one  side.  J.  Turner  (Jour, 
of  Mental  Sci.,  Apr.,  '92). 

Description  of  Plate. — Fig.  1.  Asym- 
metry of  expression  in  the  lower  part  of  the 
face  in  the  case  of  an  imbecile.  Fig.  2.  A  case 
of  acute  melancholia  with  visceral  delusions. 
Fig.  3.  Asymmetry  in  the  forehead,  assumed 
with  certain  emotional  states,  in  a  young 
phthisical  woman.  Fig.  4.  Another  instance 
of  asymmetry  in  the  forehead  in  a  case  of 
melancholia.  Fig.  5.  A  case  of  acute  melan- 
cholia. Fig.  6.  Asymmetry  of  the  forehead  in 
a  case  of  chronic  insanity.  (Turner.) 

There  is  no  relation  between  physical 
and  moral  deformities.  Individuals  who, 
from  a  moral  point  of  view,  are  depraved 
may  be  regular  physically  and  vice  versa. 
Legrain  (Le  Presse  Med.,  Dec.  21,  '95). 

What  may  be  accepted  as  a  type  of 
the  criminal,  the  insane,  epileptic,  or 
neurotic  man  has  not  yet  been  discov- 
ered. Such  a  man  bears  marks  showing 
simply  that  he  belongs  to  a  somewhat 
handicapped  family.    All  modern  studies 


Fig.  1. — Features  of  degenerated  individual. 
Physical  conformation  regular,  and  morally  a 
perfect  monster.  (Legrain.) 

seem  to  show  that  a  man  must  be  more 
than  ever  careful  of  his  education,  his 
training,  and  surroundings,  using  all 
possible  moral  and  spiritual  agencies  to 
overcome  his  defects  and  make  his 
powers  more  stable.  Ch.  Dana  (Medical 
Record,  Dec.  15,  '94). 


SYMPTOMS.  57 

Special  type  marked  by  precocious  de- 
mentia, patients  exhibiting  signs  of  de- 
generation at  age  of  17  to  20.  Malschin 
(Neurol.  Centralb.,  No.  3,  '95). 

Literature  of  '96-'97-'98. 

One  hundred  and  eight  insane  patients 
examined  with  regard  to  the  shape,  size, 
and  innervation  of  the  uvula,  the  total 


Fig.  2.— Features  of  degenerated  individual. 
Deformed  physically,  and  morally  an  inoffen- 
sive simpleton.  [Legrain.) 


number  of  deformities  found  to  be  53, 
or  almost  50  per  cent.  The  commonest 
peculiarity  was  a  twist  to  one  side,  about 
equally  to  the  right  or  to  the  left,  but  a 
little  oftener  to  the  left  side.  The  total 
number  of  patients  with  a  twisted  uvula 
was  32.  The  proportion  was  much 
greater  in  the  degenerative  forms  of  in- 
sanity, the  number  being  19  among  35 
cases,  or  over  half,  as  against  13  in  69 
cases  of  acquired  insanity.  Thus,  just  in 
proportion  as  the  physical  stigmata  of  de- 
generacy were  more  marked  the  propor- 
tion of  deformed  uvulas  increased.  Bifid 
uvula  was  not  found  in  any  case. 
Charles  L.  Dana  (Amer.  Jour,  of  In- 
sanity, Apr.,  '96) . 

Not  only  is  there  a  greater  want  of 
symmetry  in  the  outline  of  the  cranium 


58 


INSANITY.    PSYCHICAL  SYMPTOMS. 


in  the  insane,  but  the  cranial  bones  vary- 
much  in  their  thickness,  the  alteration 
taking  place  being  most  frequently  an 
hypertrophy  of  the  bones.  In  234  post- 
mortems performed  by  the  writer  (144 
males,  90  females),  the  calvaria  were  dis- 
tinctly thickened  in  fifty-one  cases  (22 
males,  29  females).  C.  F.  Beadles  (Edin- 
burgh Med.  Jour.,  vol.  xlv,  No.  513). 

As  to  whether  thickened  skulls  cause 
mental  aberration,  personal  view  ex- 
pressed that  flattening  of  one  side  of  the 
skull,  obliteration  of  the  sutures,  and 
other  irregularities  are  the  precursors  of 
affections  of  the  brain;  and  that  the 
Pacchionian  bodies  when  enlarged  may 
cause  cerebral  disturbances.  J.  F.  Bris- 
coe (Jour.  Mental  Science,  Apr.,  '98). 

Defective  mental  condition  is  associ- 
ated usually,  especially  in  the  congenital 
class  of  cases,  with  certain  physical  char- 
acteristics, such  as  a  defective  hand,  de- 
formed palate,  wandering  eye,  a  want  of 
co-ordinating  power  of  the  body  and 
limbs,  and  inertness  or  too  great  restless- 
ness. F.  Beach  (Treatment,  Oct.  13,  '98). 

Bed-sores  develop  with  great  rapidity 
in  the  insane,  especially  general  paretics 
and  epileptics.  A  peculiar  fragility  of 
the  long  bones  has  also  been  noted. 

In  chronic  disease  of  the  central  nerv- 
ous system,  especially  in  insanity,  the 
ribs  are  apt  to  undergo  very  consider- 
able morbid  changes,  which  give  rise  to 
increased  brittleness,  and  hence  predis- 
pose the  bones  to  fracture  from  the 
slightest  violence.  Constantino  vsky 
(Med.  Chronicle,  Oct.,  '90). 

Statement  denied  that  general  paraly- 
sis of  the  insane  is  accompanied  by  a 
rarefaction  of  the  osseous  tissue,  leading 
to  the  ready  production  of  fracture  and 
retarding  healing  of  bones,  when  broken. 
Christian  (La  France  Med.  et  Paris  Med., 
Apr.  21,  '93). 

Five  cases  of  osteomalacia  in  insane 
patients.  These  5  cases  were  observed 
dining  a  period  of  six  years,  in  which 
time  1500  patients  passed  under  personal 
observation.  The  patients  were  all 
women,  varying  in  age  from  37  to  0G 
years.  None  of  these  showed  symptoms 
of   general    paralysis.    Wagner  (Deut. 


Woch.  f.  Gesundheitspflege,  etc.,  No.  9, 
p.  113,  '90). 

Literature  of  '96-'97-'98. 

Personal  belief  that  mollities  ossium 
may  arise  from  gross  dietetic  errors,  that 
rickets  is  a  disease  of  growth,  and  that 
mollities  ossium  is  apparently  a  disease 
of  decay.  The  pathological  conditions  of 
bones  will  explain  the  fragility  of  the 
ribs  of  the  sane  and  of  the  insane. 

Out  of  7182  deaths  in  the  insane- 
asylums  of  England  and  Wales,  13  re- 
sulted from  diseases  of  joints  and  bones, 
and  11  from  fractures  or  dislocations. 
In  1897,  out  of  6783  deaths,  15  resulted 
from  diseases  of  joints  and  bones  and  13 
from  dislocations  and  fractures.  J.  F. 
Briscoe  (Jour.  Mental  Science,  Apr.,  '98). 

Psychical  Symptoms. — Among  these 
is  emotional  instability,  the  minor  grades 
of  which  are  especially  noticeable  in 
neurasthenic   conditions   and  hysteria. 
I  In  maniacal  states,  paranoia,  and  the 
early  stages  of  general  paresis,  the  emo- 
tional instability  is  much  heightened. 
The  patient  is  easily  "upset";  slight  irri- 
|  tants  may  cause  violent  outbreaks  of 
I  anger  or  rage  with  destructive  attacks. 
In   melancholia   the    emotional  in- 
stability tends  to  react  to  painful  impres- 
sions.   The  patient  is  easily  moved  to 
tears,  or  is  subject  to  morbid  anxiety, 
sorrow,  or  fears,  so  often  present  in  neu- 
rasthenic states  and  depressive  forms  of 
insanity. 

The  distinctive  psychical  symptoms  of 
insanity  are  sensory  and  intellectual  dis- 
turbances. The  former  are  termed  hal- 
lucinations and  illusions,  and  the  latter 

!  delusions  and  impulses. 

Hallucinations. — An  hallucination  is 
a  false  sense-perception  having  no  object- 
ive basis.  There  may  be  hallucinations 
of  the  special  senses:  hearing,  vision, 
smell,  taste,  or  of  common  sensation. 
Auditory  and  visual  hallucinations  are 

I  especially  frequent,  and  are  often  symp- 


INSANITY.    PSYCHICAL  SYMPTOMS. 


59 


toms  of  dangerous  forms  of  insanity. 
The  patient  hears  some  one  call  him  op- 
probrious names  as  he  walks  along  the 
street,  or  voices  in  the  wall,  the  chimney, 
outside  of  the  door  annoy  him.  Some- 
times the  voice  is  an  internal  one  and 
commands  him  to  kill  his  persecutor  or 
destroy  the  latter's  property.  Hallucina- 
tions of  hearing  are  especially  frequent 
in  paranoia. 

Visual  hallucinations  are  less  frequent 
than  those  of  hearing.  They  are  present 
in  paranoia,  mania,  and  epilepsy.  One 
of  the  most  dangerous  visual  hallucina- 
tions seems  to  be  that  of  "seeing  red." 
The  suggestion  of  blood  often  leads  to 
homicide. 

Hallucinations  of  taste  are  found  in 
paranoia  and  melancholia.  In  the  for- 
mer the  patient  "tastes  poison"  in  the 
food  and  hence  refuses  to  eat,  unless  he 
can  get  food  secretly.  The  hallucina- 
tions of  taste  of  the  melancholiac  are, 
perhaps,  sometimes  exaggerated  perver- 
sions of  taste  due  to  digestive  disturb- 
ances. The  same  may  be  said  of  the 
hallucinations  of  smell.  Hallucinations 
of  smell  are  not  rare  in  paranoia,  climac- 
teric insanity,  melancholia,  and  espe- 
cially, according  to  Savage  and  Krafft- 
Ebing,  in  mental  disturbances  connected 
with  ovarian  and  uterine  disease. 

The  hallucinations  of  the  various  spe- 
cial senses  are  often  associated.  Thus, 
auditory  and  visual  hallucinations  and 
those  of  smell  and  taste  are  frequently 
combined.  In  one  well-marked  case  of 
paranoia  hallucinations  of  all  the  senses 
were  present  and  caused  the  patient 
much  mental  suffering. 

Hallucinations  of  common  sensation 
often  give  rise  to  complaints  of  vermin 
crawling  upon  or  burrowing  in  the  skin. 
In  some  cases  they  are,  doubtless,  evolved 
from  paresthesia?,  being,  in  fact,  illu- 
sions, and  not  hallucinations.  Insane 


persons  frequently  tear  off  all  clothing 
and  go  about  in  a  nude  state.  This  is 
often  regarded  as  a  desire  to  exhibit  the 
nude  body,  but  it  is  probable  that  the 
clothing  is  taken  off  on  account  of  some 
sensory  disturbance  attributed  to  the 
clothing. 

Illusions. — An  illusion  is  a  sense-per- 
ception having  an  objective  basis,  but 
falsely  translated  to  the  consciousness. 
It  is  a  faulty  conception  of  an  actual 
sense-impression.  For  example,  when 
an  undefined  noise  is  heard  as  spoken 
language;  when  a  fog  is  taken  for  the 
smoke  of  a  burning  city;  when  the  pres- 
sure of  a  closely-fitting  collar  gives  the 
impression  and  causes  the  feeling  of 
strangulation, — these  are  illusions. 

Delusions. — Delusions  are  false  con- 
ceptions and  judgments.  Wood's  defini- 
tion of  a  delusion — the  best  and  clearest 
ever  formulated — is:  "A  faulty  belief 
concerning  a  subject  capable  of  physical 
demonstration  out  of  which  the  person 
cannot  be  reasoned  by  adequate  methods 
for  the  time  being." 

According  to  this  definition  all  faulty 
beliefs  or  false  judgments  are  not  de- 
lusions. A  faulty  belief  may  be  a  delu- 
sion in  one  person  and  not  in  another. 
It  is  largely  a  matter  of  education,  or  of 
environment.  Thus,  certain  political 
views  or  religious  beliefs  held  by  large 
numbers  of  the  people  appear  to  others 
as  delusions.  Persons  without  a  physical 
or  mathematical  education  may  believe 
that  perpetual  motion  and  squaring  the 
circle  are  possible.  Physicists  and  mathe- 
maticians know  that  they  are  not  pos- 
sible. The  contrary  belief  is  not  a  delu- 
sion, but  simply  ignorance.  The  preva- 
lent belief  among  some  communities  in 
the  North  during  the  late  war  between 
the  States,  that  all  rebels  had  horns,  was 
similarly  ignorance  and  not  a  delusion, 


PSYCHICAL  SYMPTOMS. 


60  INSANITY. 

although  the  writer  knew  persons  who 
held  the  belief. 

A  difference  is  made  between  insane 
and  sane  hallucinations  and  delusions. 
The  former  are  said  to  dominate  the  life 
and  acts  of  the  subject,  while  in  the  life 
and  conduct  of  the  latter  the  hallucina- 
tions and  delusions  are  merely  incidental. 
The  distinction  is  an  arbitrary  and  in- 
definite one. 

[Shakespeare  had  apparently  a  clear 
notion  of  the  difference.  In  "Macbeth," 
in  the  dagger  scene,  the  hallucination  is 
evidently  recognized  by  the  chief  actor 
as  a  false  sense-impression,  since  he  asks: 
"Art  thou  but  a  dagger  of  the  mind,  a 
false  creation  proceeding  from  the  Jieat- 
oppressed  bra  in  V  In  the  banquet-scene, 
on  the  contrary,  all  doubt  of  the  reality 
of  the  vision  has  ceased  when  he  ad- 
dresses Banquo's  apparition  as  if  there 
were  no  doubt  of  its  real  presence. 
George  H.  Rohe.] 

Delusions  are  divided  into  expansive 
delusions,  or  delusions  of  grandeur;  de- 
pressive delusions,  or  delusions  of  debase- 
ment; delusions  of  persecution,  and  re- 
ligious and  sexual  delusions.  The  delu- 
sions of  grandeur  and  of  debasement  are 
the  fundamental  varieties.  The  others 
are  mere  modifications  of  them.  Perse- 
cutory, religious,  and  sexual  delusions  are 
based  upon  some  delusion  of  exalted  or 
debased  personality.  Thus  an  insane 
person  regards  himself  as  persecuted  be- 
cause he  is  the  offspring  of  royalty, 
illegally  kept  out  of  his  rightful  sphere; 
another  is  the  saviour  of  mankind,  but, 
like  the  Son  of  God,  he  has  come  unto 
his  own  and  his  own  have  known  him 
not;  another  has  boundless  sexual  power, 
and  can  generate  a  higher  and  nobler 
class  of  beings,  but  his  enemies  destroy 
or  fraudulently  substitute  some  inferior 
being  in  the  place  of  the  paragon.  In 
all  these  phases  of  delusive  belief  the 
grandiose  character  is  maintained,  and 


the  idea  of  persecution  is  merely  a  fur- 
ther development  thereof. 

Delusions  of  grandeur  are  present  in 
general  paresis,  in  which  disease  they 
have  long  been  regarded  as  characteristic. 
They  are  also  an  essential  element  in 
paranoia,  in  which  persecutory  delusions 
are  an  outgrowth  of  them.  In  melan- 
cholia, delusions  of  debasement  are  often 
characteristic.  In  mania  delusions  of 
grandeur  are  often  transitory  and  vary- 
ing; in  general  paresis  they  are  ex- 
tremely extravagant,  and  in  paranoia 
they  are  fixed  and  in  a  sense  logical. 

Case  of  systematic  delirium  of  grand- 
eur without  noticeable  lowering  of  the 
intellect.  G.  Baliet  and  Arnaud  (An- 
nates Medico-psychol.,  Mar.,  Apr.,  '95). 

Delusions  of  debasement  or  unworthi- 
ness  are  common  in  melancholia;  they 
are  rare  in  paranoia. 

Delusions  of  persecution  are  character- 
istic of  paranoia.  In  this  form  of  in- 
sanity they  are  closely  connected  with 
hallucinations  of  hearing,  smell  and 
taste;  indeed,  delusions  in  the  majority 
of  cases  are  outgrowths  of  hallucinations. 
Persecutory  delusions  are  extremely 
dangerous  symptoms.  Under  the  influ- 
ence of  such  delusions  most  of  the  acts 
of  violence  of  the  insane  are  committed. 

Religious  delusions  are  found  in  para- 
noia, epilepsy,  and  melancholia.  In 
paranoia  and  epilepsy  they  are  nearly  al- 
ways of  an  expansive  character.  The 
subject  fancies  himself  or  herself  an  ex- 
alted religious  personage,  and  may  even 
claim  the  attributes  of  the  Diety.  In 
other  cases  he  or  she  holds  communica- 
tion with  God,  the  Saviour,  the  Virgin 
Mary,  or  some  prominent  saint.  In  these 
persons  hallucinations  of  hearing  and 
vision  are  always  present.  The  religious 
delusions  of  melancholia  are  usually  per- 
meated with  a  profound  sense  of  un- 
worthiness  of  the  subject,  while  the  para- 


INSANITY.    DIAGNOSIS.  PROGNOSIS. 


61 


noiac  is  saturated,  so  to  speak,  with  the 
sense  of  his  own  importance  and  power, 
and  is  always  convinced  that  he  is  en- 
titled to  more  honor  than  the  world 
renders  him;  the  melancholiac,  on  the 
other  hand,  constantly  and  loudly  pro- 
tests his  utter  unworthiness,  his  sinful- 
ness, the  impossibility  of  ever  regaining 
the  lost  grace  of  God. 

Sexual  delusions  of  an  expansive  char- 
acter are  present  in  the  early  stages  of 
general  paresis,  in  mania,  and  in  para- 
noia. In  the  latter  they  are  combined 
usually  with  persecutory  delusions.  The 
persistent  doubts  of  sexual  power  so 
often  found  in  neurasthenics  cannot  be 
regarded  as  delusions. 

Morbid  Impulses.  Impulsive  Acts. — 
When  an  epileptic  during  an  hallucina- 
tory aura  attacks  another  person,  a  para- 
noiac under  the  influence  of  his  perse- 
cutory delusions  commits  murder,  or  a 
sexual  pervert  cohabits  with  animals  or 
with  dead  bodies,  the  acts  are  said  to  be 
impulsive,  and  committed  in  obedience 
to  an  imperative  impulse,  conception,  or 
idea.  The  Germans  call  these  impulses 
u Zwangsvorstellungen"  literallv  coercive 
conceptions.  The  French  term  is  "obses- 
sions." The  numerous  so-called  mono- 
manias and  monophobias  of  authors  be- 
long to  this  class  of  symptoms.  Thus 
suicidal  and  homicidal  mania,  dipso- 
mania, pyromania,  kleptomania,  eroto- 
mania, onomatomania,  are  not  special 
varieties  of  insanity,  but  the  manias  are 
merely  coercive  impulses,  often  irresist- 
ible. 

An  impulsive  tendency  to  suicide  does 
not  constitute  a  special  variety  of  in- 
sanity; it  is  merely  a  symptom  of  a  de- 
pressive mental  state.  It  is  most  fre- 
quently a  symptom  of  melancholia,  but 
may  be  present  in  other  forms  of  mental 
disturbance. 

General  Diagnosis. — The  differentia- 


tion of  the  individual  forms  of  insanity 
is  often  difficult,  but  it  is  still  more  diffi- 
cult at  times  to  say  with  positiveness  that 
a  person  under  examination  is  sane  or  in- 
sane. This  is  largely  due  to  the  fact  that 
there  is  no  absolute  standard  of  sanity. 
The  outward  expression  of  insanity  of 
thought  and  feeling  is  manifested 
through  conduct,  but  as  there  is  no  gen- 
eral standard  of  sane  conduct,  it  is  neces- 
sary to  compare  the  conduct  of  the 
person  in  question  with  the  conduct  of 
the  generality  of  persons  living  under 
the  same  environments  or  to  compare 
the  conduct  of  the  subject  with  his  own 
previous  mode  of  life.  The  behavior  of 
a  thief,  a  tramp,  a  drunkard,  or  a  prosti- 
tute is  not  approved  by  society,  but  the 
thief  and  his  proscribed  companions  are 
not  considered  as  insane,  either  by  so- 
ciety in  general  or  by  each  other.  But 
if  a  clergyman  becomes  a  thief;  a  million- 
aire, a  tramp,  an  ascetic,  a  drunkard;  or 
one  who  has  hitherto  been  a  model  of 
womanly  virtue  a  prostitute,  there  are 
grave  reasons  for  suspecting  the  sanity 
of  the  person  thus  offending.  The  gen- 
eral diagnosis  of  insanity  must  take  into 
account  not  only  the  subject's  conduct 
at  the  time  being,  but  his  previous  his- 
tory and  his  environment.  Specific  de- 
tails will  be  given  in  the  consideration 
of  the  special  forms  of  insanity 

General  Prognosis. — Contrary  to  com- 
mon belief,  insanity  is  curable  in  a  con- 
siderable proportion  of  cases.  If  appro- 
priate treatment  is  promptly  instituted 
the  recovery-rate  of  all  cases  should 
reach  at  least  40  per  cent.  If  certain 
groups  that  are  incurable,  such  as  imbe- 
cility, paranoia,  general  paresis,  and 
epileptic  and  other  secondary  dementias 
are  excluded,  the  proportion  of  recoveries 
should  be  much  larger.  It  is  not  un- 
reasonable to  expect  recovery  in  75  per 


62 


INSANITY.    GENERAL  PRINCIPLES  OF  TREATMENT. 


cent,  of  the  psychoses  due  to  nutritive 
disturbances  or  toxic  conditions. 

The  prognosis  of  insanity  in  childhood 
is,  on  the  whole,  favorable  if  there  is  no 
neuropathic  ancestry.  If,  however,  the 
child  shows  evidences  of  psychopathic 
heredity,  the  prognosis  is  bad.  Moreau 
de  Tour  (Annales  d'Hyposologie  et  de 
Psych.,  Dec,  '91). 

Of  2176  insane  persons  admitted  into 
the  Eastern  Michigan  Asylum,  378,  or 
17.3  per  cent.,  recovered  without  relapse; 
91,  or  4.1  per  cent.,  recovered,  relapsing 
one  or  more  times;  256,  or  11.1  per  cent., 
were  discharged  improved,  remaining  at 
home  without  again  resorting  to  the 
asylum;  and  522,  or  23.9  per  cent.,  died. 
The  low  absolute-recovery  rate  is  due  to 
the  fact  that  all  sorts  of  cases  in  various 
stages  of  chronic  insanity  are  admitted. 
E.  A.  Christian  (Amer.  Lancet,  May,  '94). 

The  insane  succumb  in  but  a  small 
proportion  to  infectious  disease  as  com- 
pared with  the  general  population.  Of  i 
15,248  deaths  in  Italian  asylums,  8.46  per 
cent,  were  due  to  tuberculosis,  4.16  per 
cent,  to  pneumonia,  and  1.75  per  cent, 
to  typhoid  fever.  Of  307,477  deaths  in 
the  general  population,  12.22  per  cent, 
were  from  tuberculosis,  15.50  per  cent, 
from  pneumonia,  and  2.95  per  cent,  from 
typhoid  fever.  Gucci  (Centralb.  f.  Ner- 
venheilkunde,  etc.,  No.  26,  '89). 

Literature  of  '96-'97-'98. 

The  influence  of  microbian  diseases 
among  the  insane  leads,  in  the  majority 
of  cases,  when  the  subjects  are  young, 
to  a  more  or  less  considerable  ameliora- 
tion of  the  mental  condition.  M.  Rene 
Charon  (Archives  de  Neurol.,  May,  '96).  j 

The  majority  of  authors  agree  that 
the  prognosis  of  insanity,  complicated 
by  "insane-ear,"  is  sufficient  evidence  of 
its  incurability,  while  a  few  contend  j 
that  there  are  cases  in  which  perfect  re-  I 
covery  has  taken  place.  Out  of  7000  ad- 
missions to  the  Connecticut  Hospital  for 
the  Insane  there  was  only  one  case  that 
developed  hsematoma  aurium  and  re- 
mained well.  L.  P.  Clark  (Amer.  Med.- 
Surg.  Bull.,  Aug.  22,  '96). 

Decidedly  hereditary  cases  of  insanity 
are  often  the  most  curable,  although 


there  is  more  likelihood  of  a  relapse  than 
in  those  in  which  the  hereditary  tend- 
ency is  absent. 

It  has  been  estimated  that  63  per  cent, 
of  recoveries  from  insanity  take  place 
before  the  age  of  twenty-five,  although 
the  young  are  more  subject  to  relapses. 
The  menopause  is  another  period  of  life 
at  which  recovery  occurs  in  many  cases; 
but  the  disease  is  usually  of  long  dura- 
tion, not  ending  until  the  cessation  of 
the  menstrual  function  is  complete. 
Genuine  climacteric  insanity,  however,  is 
rare. 

Acute  forms  of  insanity  in  which  re- 
covery is  especially  apt  to  occur  are 
stuporous  insanity,  or  so-called  primary 
dementia;  confusional  insanity;  puer- 
peral and  lactation  insanity;  and  that 
which  follows  acute  physical  disorders. 
But  systematized  delusional  insanity  be- 
longs to  the  chronic  class  and  is  rarely 
curable.  The  secondary,  or  terminal, 
stage,  dementia,  as  well  as  recurrent  and 
alternating  insanity,  is  hopelessly  in- 
curable. 

General  paralysis  of  the  insane  is  al- 
most inevitably  fatal.  Henry  R.  Sted- 
man  (Boston  Med.  and  Surg.  Jour.,  June 
10,  '97). 

Generally  one  may  say  that  if  a  child 
has  an  attack  of  mania,  melancholia,  or 
other  mental  affection,  and  there  is  no 
history  of  hereditary  predisposition  or 
masturbation,  the  prognosis  will  be 
favorable;  on  the  other  hand,  if  heredity 
is  well  marked  and  masturbation  is 
much  practiced,  the  prognosis  will  be 
bad,  especially  as  regards  the  future.  An 
exception  must  be  made  in  the  cases  of 
juvenile  dementia  the  result  of  heredi- 
tary syphilis,  moral  insanity,  general 
paralysis,  and  usually  by  nymphomania 
and  satyriasis.  In  these  cases  the  prog- 
nosis is  always  bad.  Fletcher  Beach 
(Jour.  Mental  Science,  July,  '98). 

General  Principles  of  Treatment. — In- 
asmuch as  insanity  is  here  considered  as 
purely  physical  disease,  it  is  evident  that 
purely  psychical  remedies  occupy  a  very 
subordinate  part  in  the  treatment.  They 
are  limited  to  what  may  he  called,  in  a 
i  general  war.  the  management,  or  hand- 


INSANITY.    GENERAL  PRINCIPLES  OF  TREATMENT. 


03 


ling,  of  the  patient.  A  tactful  nurse — ■ 
one  who  combines  the  suaviter  in  modo 
with  the  fortiter  in  re — is  here  essential. 
Agreeable  surroundings  and  keeping  at 
a  distance  sources  of  irritation  may  also 
be  classed  with  the  psychical  remedies. 
Isolation  is  not  to  be  recommended,  espe- 
cially in  hallucinatory  and  delusional 
forms. 

Eegarding  the  much-discussed  ques- 
tion of  institutional  or  home  treatment, 
the  decision  should  in  all  cases  be  in 
favor  of  the  former.  It  is,  of  course,  as- 
sumed that  the  institution  is  up-to-date 
in  all  respects,  and  that  the  treatment  is 
according  to  modern  methods. 

The  general  physical  treatment  con- 
sists in  good  food,  rest  in  bed  in  acute 
cases,  and  out-door  life  after  the  acute 
stage  is  over  and  danger  of  exhaustion 
has  passed. 

Literature  of  '96-'97-'98. 

Systematic  employment  and  training 
of  the  insane  is  the  keystone  to  modern 
treatment  of  the  insane.  Edward  D. 
O'Neill  (Jour,  of  Mental  Science,  Apr., 
'96). 

In  the  majority  of  cases  it  will  be 
found  that  the  digestive  and  assimilative 
functions  require  attention,  and  that  re- 
storative tonics  are  indicated. 

Mental  disease  is  usually  attended 
with  malnutrition,  and  in  treating  in- 
sanity the  nutrition  should  be  made  as 
perfect  as  possible,  and  as  soon  as  pos- 
sible. A.  R.  Moulton  (Amer.  Jour.  In- 
sanity, Oct.,  '94). 

Insomnia  can  generally  be  combated 
by  baths,  out-door  life,  attention  to  hours 
of  feeding,  proper  bed-clothing,  and, 
when  necessary,  hypnotics.  These  medi- 
cines should,  however,  be  avoided  if  pos- 
sible, as  they  are  nearly  always  attended 
by  some  untoward  effects. 

In  the  comparison  of  narcotics  and 
hypnotics  they  are  ranged  in  the  follow- 


ing scale:  Morphine,  chloral,  amylene- 
hydrate,  paraldehyde,  and  sulphonal.  If 
they  were  arranged,  howrever,  in  order  of 
hypnotic  power,  and  at  the  same  time 
their  innocuousness,  they  stand  in  the 
following  order:  Chloral,  sulphonal, 
amylene-hydrate,  paraldehyde,  and  mor- 
phine. Jastrowitz  (Deut.  med.  Woch., 
Aug.  1  to  20,  '89). 

Curious  instance  of  aphasia  that  ap- 
peared in  an  hemiplegic,  following  the 
administration  of  15  grains  of  sulphonal. 
Sleep  was  produced  which  lasted  the  en- 
tire night,  but  upon  the  following  morn- 
ing the  patient  was  completely  aphasic, 
and  this  condition  lasted  for  eight  or 
ten  hours,  the  patient  meanwhile  feeling 
very  debilitated.  Kisch  (Berl.  klin. 
Woch.,  No.  7,  '89). 

Sulphonal  administered  to  forty-one 
insane  females.  Disagreeable  effects  fre- 
quently observed:  frequent  spitting,  un- 
easiness, vomiting,  staggering  gait,  and 
sometimes  diarrhoea.  If  sulphonal  was 
discontinued  the  patients,  without  excep- 
tion, recovered  completely.  It  should 
never  be  given  in  daily  doses  of  30  to  45 
grains  more  than  several  months  without 
discontinuing  it  from  time  to  time. 
Schedtler  (Therap.  Monats.,  June,  '95). 

Forty-six  to  62  grains  of  sulphonal  are 
necessary  to  get  the  best  hypnotic  effect. 
Sleep  is  produced  quite  rapidly.  The 
same  persistence  of  the  hypnotic  effect 
after  the  suspension  of  the  drug  is  ob- 
served. The  nervous  disturbances  from 
sulphonal  are  divided  into  four  groups: 

(1)  those  which  compare  to  the  well- 
known  feelings  in  the  morning,  after  a 
heavy  drinking-bout  of  the  night  before; 

(2)  that  of  drunkenness,  with  all  its  pe- 
culiar individual  traits;  (3)  where  idea- 
tion and  memory  are  failing;  (4)  those 
of  stupor,  vertigo,  difficulty  in  walking 
and  speech,  and  even  paresis  of  the  limbs. 
Marandon  de  Montyel  (La  France  Med., 
Nov.  14,  '89). 

Sulphonal  found  useful  in  many  cases 
among  the  insane,  and  comparatively 
inert  among  others.  In  100  cases  it  was 
followed  with  80  per  cent,  of  successes, 
the  average  time  in  which  sleep  came  on 
being  three  hours.  The  average  dose  ad- 
ministered was  12  grains.    L.  C.  Toney 


INSANITY.    GENERAL  PRINCIPLES  OF  TREATMENT. 


(St.  Louis  Med.  and  Surg.  Jour.,  Jan., 
'91). 

In  comparing  trional  with  sulphonal, 
preference  given  to  the  former  as  an  hyp- 
notic. Steiner  (Deutsche  med.  Woch., 
No.  13,  '95). 

Unusual  toxic  effect  of  trional  ob- 
served in  a  case  of  insomnia  when  re- 
newed small  doses  were  administered. 
J.  W.  Irwin  (Amer.  Therapist,  Oct.,  '95). 

The  special  and  elective  action  of 
potassium  bromide  on  the  bulbar  region, 
with  elective  action  of  opiates  and 
chloral  on  cerebral  lobes,  may  be  advan- 
tageously combined.  The  following 
mixture  recommended; — 

I£  Potassium  bromide,  2  drachms. 

Chloral-hydrate,  x/2  drachm. 

Syrup  of  morphine  (French  Codex, 
V6  grain  to  the  ounce),  1  ounce. 

Distilled  water,  3  1/2  ounces. — M. 
Luys  (Lyon  Med.,  July  14,  '95). 

Chlorobrom — a  mixture  of  equal  parts 
of  potassium  bromide  and  chloralamid 
dissolved  in  water — has  less  action  upon 
the  heart  and  blood-vessels  than  chloral. 
Not  particularly  disagreeable  to  take  and 
leaves  no  ill  after-effects.  Wade  (Amer. 
Jour,  of  Insanity,  Apr.,  '95). 

The  hydrochlorate  of  morphine  is  of 
great  value  in  the  treatment  of  mental 
and  nervous  disorders.  Aug.  Voisin 
(Bull.  Gen.  de  Ther.,  Apr.  15,  '91). 

In  the  employment  of  hypnotic  meas- 
ures excellent  results  may  be  obtained 
with  the  wet  pack.  Though  it  produces 
sleep  in  patients  with  a  very  high  de- 
gree of  excitement,  in  some  cases  it  be- 
came necessary  to  repeat  the  application 
frequently  for  a  period  extending  over 
half  a  year,  but  no  diminution  in  its 
effects  were  observed.  Umpfenbach 
(Ther.  Monats.,  June,  '89). 

Literature  of  '96-'97-'98. 

Lactophen  given  for  insomnia  in  over 
200  cases,  with  very  good  results.  The 
dose  given  varied  from  15  to  45  grains, 
the  drug  being  administered  in  some 
sweet  emulsion.  Like  most  hypnotics,  it 
loses  its  effect  after  continued  use,  but 
after  a  short  intermission  can  be  used 
again  with  good  results.    It  is  quite  safe 


and  more  generally  useful — in  insane 
subjects — than  opium,  chloral,  trional,  or 
other  hypnotics.  Cristiani  (Rif.  Med., 
June,  '98). 

Opium  is  rarely  necessary  in  insanity 
in  children;  when  sedatives  are  required, 
a  warm  bath  daily  will  be  found  useful, 
and  when  there  is  intense  delirium  one 
can  add  to  this  the  application  of  cold 
to  the  head;  in  other  cases  a  wet  pack 
will  be  preferable.  The  administration 
of  bromide  of  sodium  in  doses  according 
to  the  age  of  the  child  will  act  as  a 
calming  agent,  especially  in  cases  of  epi- 
leptic mania.  In  cases  where  there  is 
much  sleeplessness  trional,  in  doses  of 
from  3  to  8  grains,  may  be  given  for  a 
few  nights.  A  tonic  treatment  is  to  be 
pursued,  and  in  those  who  masturbate 
the  administration  of  quinine  and  cam- 
phor will  be  found  convenient.  Care 
must  be  taken  to  keep  the  bowels  well 
open.  Open-air  exercise  is  to  be  em- 
ployed in  all  cases,  but  gymnastics 
should  be  made  use  of  as  a  recreation  in 
cases  of  melancholia,  and  as  a  regulator 
of  movements  in  choreic  insanity.  In 
some  cases  it  will  be  necessary  to  stop 
all  intellectual  occupation;  in  others  to 
encourage  it,  and  also  to  make  the  child 
interested  in  the  general  affairs  of  life. 

One  of  the  most  important  parts,  if 
not  the  most  important,  of  the  treatment 
is  the  separation  of  the  child  from  his 
friends.  Visits  from  friends  should  be 
permitted  rarely  at  first,  and  regarded  as 
a  favor  or  reward  for  good  behavior. 

Children  suffering  from  moral  insanity 
should  be  put  into  institutions  in  which 
they  should  undergo  industrial  training, 
and  be  kept  under  control  during  the 
period  of  their  lives. 

The  prevention  of  insanity  in  childhood 
is  most  important.  Life  in  the  open  air, 
work  in  a  garden  or  on  a  farm,  recrea- 
tion of  all  sorts,  absence  of  forced  pro- 
longed intellectual  labor,  and  the  sup- 
pression of  excessive  emotion  are  the 
chief  hygienic  indications  in  those  pre- 
disposed to  insanity.  Fletcher  Beach 
(Journal  of  Mental  Science,  July,  '98). 

When  food  is  refused  on  account  of 
gastric  derangement,  lavage  of  the  stom- 
ach and  careful  systematic  feeding  will 


INSANITY.    GENEKAL  PRINCIPLES  OF  TREATMENT. 


05 


soon  correct  the  disturbance.  Refusal 
owing  to  hallucinations  and  delusions 
may  sometimes  be  overcome  by  tactful 
solicitation,  but  in  other  cases  forced  ali- 
mentation must  be  resorted  to.  Often 
the  tubular  mouthed  vessel  called  a 
"duck"  will  enable  sufficient  liquid  food 
to  be  introduced.  Where  this  is  not  suc- 
cessful the  food  must  be  given  through  a 
nasal  or  oesophageal  tube.  Many  alien- 
ists prefer  the  former,  but  in  the  experi- 
ence of  the  writer  the  oesophageal  tube 
is  as  convenient  as  the  other,  and  its 
larger  calibre  allows  the  requisite  quan- 
tity of  food  to  be  introduced  into  the 
stomach  more  rapidly. 

Care  must  be  taken  to  vary  the  food 
given  through  the  tube.  The  constant 
use  of  milk  or  milk  and  eggs  often 
offends  the  stomach  and  failure  of  diges- 
tion results.  Such  vegetables  as  potatoes, 
Tice,  beans,  peas,  or  lentils  can  be  mashed 
and  reduced  with  milk  to  a  thick  fluid 
mass,  easily  passed  through  the  tube. 
Beef  can  also,  after  thorough  boiling,  be 
pounded  in  a  mortar,  or  ground  in  a 
meat-grinder  and  likewise  reduced  to  a 
thick  paste.  The  various  beef-juices 
(not  extracts)  and  beef-powders,  such  as 
Mosqueras,  or  peptonoids,  may  also  be 
given  in  the  same  way. 

(See  Anorexia  Nervosa,  volume  i.) 

Sitiophobia  treated  by  first  washing 
out  the  stomach  through  the  stomach- 
tube,  and  then  introducing  food  through 
the  same  tube.  There  is,  in  most  cases 
of  refusal  of  food,  a  catarrhal  state  of 
the  stomach  at  the  bottom  of  the  hal- 
lucinations. Voisin  (Bull.  Gen.  de  Ther., 
-Ian.  30,  '91). 

Literature  of  '96-'97-'98. 

Complete  refusal  of  food  for  twenty- 
four  hours  by  a  strong,  well-nourished 
patient,  and  the  missing  of  two  meals 
by  a  feeble  one  considered  sufficient  in- 
dications for  the  stomach-tube.  Harris- 
Liston  (Brit.  Med.  Jour.,  Feb.  13,  '97). 

4—5 


I  have  found  the  subcutaneous  in- 
fusion of  an  albumin-salt  solution  ex- 
tremely valuable  in  cases  of  sitiophobia, 
as  well  as  in  other  conditions  in  which 
food  could  not  be  taken  into  or  retained 
in  the  stomach.  The  fluid  consists  of  a 
pint  of  sterilized  normal  salt  solution 
(0.6  per  cent,  chloride  of  sodium,  about 
•45  grains  to  the  pint)  in  which  the  whites 
of  two  eggs  have  been  whipped  up  and 
the  whole  strained  through  gauze.  This 
is  put  into  a  nasal-douche  bottle,  to  the 
tube  of  which  is  attached  an  aspirator- 
needle  of  small  calibre.  The  skin  over 
the  back,  loins,  or  buttocks  is  disinfected 
and  after  the  fluid  is  allowed  to  flow 
through  the  tube  and  needle  to  get  rid  of 
the  contained  air,  the  point  of  the  needle 
is  inserted  well  under  the  skin.  The 
bottle  is  then  moderately  elevated  and 
the  fluid  allowed  slowly  to  penetrate  the 
connective  tissue.  It  takes  about  fifteen 
minutes  to  infuse  a  pint  of  fluid  under 
the  skin.  The  prominent  swelling  which 
results  usually  disappears  in  the  course 
of  an  hour  or  two.  The  proceeding  is 
not  very  painful,  and  leaves  no  bad  local 
after-effects. 

Case  of  somatic  insanity  treated  by 
means  of  subcutaneous  injections  of  salt 
solution,  two  quarts  a  day  being  used 
until  15  quarts  had  been  introduced. 
The  improvement  was  marked  and  im- 
mediate. G.  F.  Keene  (Boston  Med.  and 
Surg.  Jour.,  Oct.  4,  '94). 

Literature  of  '96-'97-'98. 

In  some  cases  of  acute  mental  disease, 
cases  showing  autoinfective  symptoms, 
and  in  cases  refusing  food,  excellent  re- 
sults have  followed  the  employment  by 
hypodermic  transfusion  of  large  quanti- 
ties (one  litre)  of  0.75-per-cent.  blood- 
warm  sterilized  solution  of  sodium  chlo- 
ride. The  injections  are  made  into  the 
loose  areolar  tissue  of  the  abdominal  wall 
or  gluteal  region  once  daily.  James  T. 
Searcy  (Alienist  and  Neurol.,  Apr.,  '97). 


66 


INSANITY.    IDIOCY  AND  IMBECILITY. 


Among  the  means  of  treatment  em- 
ployed in  acute  cases  of  insanity,  none 
surpasses,  in  effect,  rest  in  bed.  The  pa- 
tient with  acute  confusional  insanity, 
mania,  or  melancholia,  usually  comes 
under  the  notice  of  the  physician  in  a 
condition  of  great  exhaustion.  Bed-rest 
in  these  cases  is  imperative.  I  have 
found  it  better  in  these  cases  to  treat  the 
patient  in  an  open  ward,  in  the  presence 
of  other  patients,  and  not  in  an  isolating 
chamber.  The  suggestive  influence  of 
other  persons  in  bed  and  apparently  sick 
has  a  favorable  effect,  and  the  patient 
soon  yields  to  the  suggestions  of  physi- 
cians and  nurses  and  regards  himself  as 
sick  and  in  need  of  treatment. 

The  insane  should  be  regarded  simply 
as  sick  persons;  they  should  be  removed 
to  hospitals,  or  detained  there  in  the 
same  manner  as  cases  of  infectious  dis- 
ease are  taken  in  charge  and  isolated  by 
the  health  authorities.  Stephen  Smith 
(Amer.  Jour,  of  Insanity,  Jan.,  '94). 

Literature  of  '96-'97-'98. 

In  a  great  number  of  cases  of  fully 
developed  mental  disease  of  some  stand- 
ing, with  fits  of  alarm,  hallucinations, 
maniacal  excitement,  etc.,  the  symptoms 
yield  to  rest  of  one  or  two  weeks  in  bed, 
whereas  in  other  circumstances  a  much 
longer  time  would  certainly  be  required. 
L.  Meyer  (Jour,  of  Mental  Sci.,  Apr., 
'96). 

Twenty-eight  male  patients,  including 
8  general  paralytics,  6  cases  of  dementia, 
5  of  melancholia,  4  of  paranoia,  and  1 
each  of  catatonia,  psychosis,  hysterica, 
senile  dementia,  and  cerebral  syphilis 
treated  with  complete  rest  in  bed.  The 
weight  of  the  patient  usually  fell  at  first, 
but  increased  again  after  some  weeks. 
As  regards  the  duration  or  cure  of  the 
disease,  bed-treatment  has  no  influence. 
Trapesnikow  (Neurol.  Centralb.,  p.  142. 
'98). 

Series  of  female  patients  treated  by 
rest  in  bed.  including  3  eases  of  secondary 
dementia,  1  of  chronic  paranoia,  2  with 
chronic  hallucinations.  2  witli  amentia. 


and  1  each  with  maniacal  exaltation,, 
melancholia,  circular  insanity,  periodic 
insanity,  and  organic  cerebral  dementia. 
In  some  patients  good  results  were  ob- 
tained, but  not  in  all.  Weight  was  often 
lost,  and  sleep,  appetite,  and  the  action 
of  the  bowels  were  all  prejudicially  in- 
terfered with,  and  hypnotics  had  to  be 
used  just  as  frequently.  Bed-treatment 
is  only  useful  for  individual  cases. 
Ossipow  (Neurol.  Centralb.,  p.  142,  '98). 

Mechanical  restraint  and  seclusion  in  a 
dark  or  barred  room  are  not  necessary  in 
the  treatment  of  insanity  in  any  of  its 
forms  and  should  never  be  employed. 

Literature  of  '96-'97-'98. 

There  is  a  class  of  cases  in  which  the 
use  of  mechanical  restraint  is  beneficial, 
but  it  should  never  be  used  except  for 
the  protection  of  the  patient;  and  not 
for  cases  of  violence  or  destructiveness. 
P.  Maury  Deas  (Jour,  of  Mental  Science,. 
Jan.,  '96). 

Emphatic  condemnation  of  the  custom 
of  using  dark  cells  for  the  purposes  of 
punishment  in  prisons,  the  main  cause  of 
insanity  among  long-term  prisoners. 
Twenty-three  per  cent,  of  the  life-men  in 
the  prisons  of  the  State  of  New  York 
are  inmates  of  the  Matteawan  State  Hos- 
pital to-day.  Most  of  them  are  hope- 
lessly insane.  H.  E.  Allison  (Albany 
Med.  Annals,  Dec,  '97 ). 

Special  Forms  of  Insanity. 

Geoep  I.  Psychoses  dee  to  Imper- 
fect Development  of  the  Bratx. 

Idiocy  and  Imbecility.  —  These  two 
conditions  of  defective  mental  function 
are  merely  different  in  degree.  They  are 
both  dependent  upon  defective  or  ar- 
rested cerebral  development.  This  de- 
fective development  may  be  hereditary, 
congenital,  or  acquired:  that  is.  it  may 
occur  in  intra-uterine  life,  during  the 
parturient  process  or  after  birth.  In  the 
United  States  idiots  and  imbeciles  are 
generally  grouped  under  the  term 
"feeble-minded." 


INSANITY.  IDIOCY 


AND  IMBECILITY. 


or 


Idiots  sometimes  appear  to  be  without 
any  intellectual  development  whatever, 
having  no  power  of  thought,  memory,  or 
judgment.  But  these  extreme  degrees,  if 
they  occur  at  all,  are  rare.  The  sensory 
organs  may  be  normal,  and  the  vegetative 
functions  well  performed. 

In  imbecility  the  arrest  or  perverted 
development  of  the  brain  has  not  pro- 
ceeded to  the  same  degree,  and  there  is 
more  or  less  intellectual  power.  The 
memory  and  certain  special  faculties,  as 
the  musical,  are  sometimes  highly  de- 
veloped in  imbeciles. 

Frequency. — The  proportion  of  feeble- 
minded is  about  1  in  500  of  population. 
Males  outnumber  females  2  to  1. 

Causation. — Idiocy  and  imbecility  are 
hereditary  in  about  one-half  of  all  cases. 
The  principal  conditions  in  the  ancestry 
supposed  to  influence  the  heredity  are 
insanity,  nervous  diseases,  intemperance, 
consanguinity,  and  tuberculosis.  Con- 
trary to  general  belief,  intemperance  in 
the  parents  is  a  factor  in  only  about  10 
per  cent. 

The  physical  characteristics  are  trans- 
mitted by  inheritance.  Mental  recep- 
tivity transmissible.  Idiocy  and  imbe- 
cility may  be  a  defect,  having  an  origin 
in  consanguineous  marriages,  prenatal 
conditions,  accidents,  arrested  develop- 
ment, infantile  meningitis,  tuberculosis, 
lack  of  potency  on  the  part  of  one  of 
the  parents  from  unexplained  causes. 
Chapin  (Phila.  Polyclinic,  Mar.  23,  '95). 

In  a  careful  examination  into  the 
family  history  of  1044  idiots,  there  were 
found  397  families,  or  38  per  cent.,  with 
a  history  of  insanity  or  imbecility,  and 
225,  or  about  21 1/2  per  cent.,  of  various 
neuroses.  While  consanguinity  is  com- 
monly accounted  a  fruitful  cause  of 
idiocy,  comparative  investigation  shows, 
first,  that  children  having  botli  mental 
and  physical  defects  are  the  offspring  of 
healthy  unrelated  parents;  second,  that 
perfectly  developed  children  with  no 
personal  peculiarities  whatsoever  may  be 


the  issue  of  consanguineous  marriages. 
M.  W.  Barr  (Jour.  Nervous  and  Mental 
Dis.,  June,  '95) . 

Literature  of  '96-'97-'98. 

In  an  area  of  four  square  miles  in 
County  Meath,  Ireland,  with  a  popula- 
tion of  about  300  persons,  one-half  of  the 
families  have  one  or  more  insane,  sui- 
cidal, idiotic,  or  goitrous  members.  At- 
tributed to  consanguinity  and  heredity, 
as  the  conditions  under  which  the  people 
live  and  their  agricultural  employment 
neither  account  for  the  endemic  nor  serve 
to  limit  it.  Laffan  (Brit.  Med.  Jour., 
Sept.  26,  '96). 

A  considerable  proportion  of  cases  of 
feeble-mindedness  is  doubtless  due  to 
traumatisms  during  the  process  of  birth. 
Prolonged  labor,  subjecting  the  brain  to 
undue  compression,  direct  traumatisms 
from  the  use  of  instruments  or  improper 
methods  of  delivery;  convulsions  in  the 
mother,  with  consequent  poisoning  of  the 
foetal  blood  by  carbon  dioxide  or  by  anaes- 
thetics used  to  relieve  the  maternal  con- 
vulsions; or  premature  birth  may  pro- 
duce such  a  disturbance  of  nutrition  in 
the  brain  as  to  arrest  or  retard  its  de- 
velopment. It  is  probable  that  the  num- 
ber of  children  in  whom  the  arrest  of  de- 
velopment has  begun  at  the  time  of  birth 
is  much  greater  than  is  generally  sup- 
posed. Many  of  the  cases  of  idiocy  and 
imbecility  among  the  offspring  of  parents 
entirely  healthy,  or  of  high  intellectual 
ability,  and  which  furnish  such  choice 
food  for  heartless  gossip  among  the 
ignorant  and  uncharitable  doubtless  be- 
gin as  the  result  of  some  such  avoidable 
or  unavoidable  accident.  The  actual  pro- 
portion is  not  ascertainable. 

Acquired  idiocy,  beginning  in  in- 
fancy or  childhood,  is  due  to  the  toxic 
influence  of  infectious  diseases,  to  in- 
juries, rachitis,  meningeal  inflammation, 
fright,  convulsions,  and  improper  train- 
ing. 


68 


INSANITY.    IDIOCY  AND 


IMBECILITY.  SYMPTOMS. 


Literature  of  '96-'97-'98. 

Both  idiocy  and  imbecility  may  be  de- 
pendent upon  early  epilepsy,  but  the 
absence  of  spastic  symptoms,  contract- 
ures, strabismus,  and  other  deformities, 
together  with  the  absence  of  progressive 
deterioration  associated  with  the  occur- 
rence of  the  convulsions,  is  character- 
istic of  the  acquired  type  rather  than  the 
hereditary.  Theodore  B.  Hyslop  (Med. 
Press  and  Circular,  Feb.  20,  '96). 

Symptoms. — The  physical  stigmata  of 
degeneration  are  well  marked  in  idiocy. 
Of  these  the  most  notable  is  micro- 
cephaly, or  abnormal  smallness  of  the 


Irregularity  or  asymmetry  of  the  skull 
and  brain  are  also  present  at  times. 

Defective  development  of  the  re- 
mainder of  the  body  is  frequent. 

Eleven  cases  of  funnel-breast  collected 
from  the  literature  and  five  new  cases 
reported.  Funnel-breast  is  one  sign  of 
physical  degeneration.  In  ten  of  the  re- 
ported cases  there  were  hereditary  psy- 
chopathic conditions  (idiocy,  epilepsy, 
imbecility,  and  delusional  insanity).  In 
only  one  of  the  cases  was  there  slight 
scoliosis.  No  evidence  of  rachitis.  In 
the  other  cases  the  history  was  incom- 
plete.    J.    Ramadier    and    P.  Serieux 


Funnel-shaped  thorax.    {Ramadier  and  Serieux.) 


cranium.  This  may  be  due  either  to  im- 
perfect growth  of  the  brain  from  in- 
trinsic causes,  or  to  premature  closure 
and  ossification  of  the  cranial  sutures. 
The  last-named  cause  was  formerly  sup- 
posed to  be  much  more  potent  than  it  is 
regarded  at  preseut. 

In  contrast  to  microcephaly,  many 
cases  of  idiocy  show  a  larger  skull  than 
normal.  In  these  cases  there  is  usually 
hydrocephalus,  which  may  sometimes  he 
extreme. 


(Nouvelle  Icon,  de  la  Salpetriere,  Sept., 
Oct.,  "91). 

The  comparative  smallness  and  weak- 
ness of  the  heart  peculiar  to  idiots  is 
general,  and  not  the  result  of  atrophy  or 
degeneration  following  disease.  The  di- 
minished size  of  the  heart  is  greater  in 
proportion  than  the  diminished  size  of 
the  brain.  Wulff  (Jour,  of  Mental  Sci- 
ence, Jan..  '05). 

Pareses  and  paralyses  are  among  the 
physical  symptoms  often  noted.  Epi- 
lepsy and  other  forms  of  convulsions  are 


INSANITY.    IDIOCY  AND  IMBECILITY.    DIAGNOSIS.  PROGNOSIS. 


69 


also  frequent  complications.  There  may 
be  various  tics,  athetosis,  and  atrophy  of 
paralyzed  limbs.   Strabismus  is  common. 

Deafness  is  extremely  uncommon 
among  the  feeble-minded;  on  the  con- 
trary, an  acuity  of  hearing  with  a  con- 
siderable development  of  the  musical 
sense,  is  not  infrequent. 

Psychical  Symptoms. — The  defect- 
ive intelligence  is  the  most  marked  char- 
acteristic of  the  idiot.  There  may  be 
shrewdness,  or  rather  cunning,  a  reten- 
tive memory,  acuteness  of  the  special 
senses,  and  even  the  mathematical 
faculty  may  be  highly  developed  in  cer- 
tain directions,  but  judgment  and  self- 
control  are  lacking.  There  is  nearly  al- 
ways defect  of  articulation;  indeed, 
articulate  voice  may  be  absent  altogether, 
the  only  vocal  sound  the  idiot  can  make 
being  an  inarticulate  cry.  The  expres- 
sion is  generally  placid  and  good-natured. 
He  seems  often  to  feel  the  necessity  of 
guidance,  and  fawns  upon  those  with 
whom  he  comes  in  contact.  At  other 
times,  however,  especially  when  his  train- 
ing has  been  neglected  and  he  has  ac- 
quired bad  habits,  his  expression  may  be- 
come brutifled.  At  best,  the  idiot  is  not 
an  agreeable  companion. 

Self-control  is  often  lacking.  The 
slightest  irritation  causes  an  outbreak  of 
rage  during  which  he  may  commit 
violence.  Sexual  instincts  are  often  ac- 
tive. Masturbation  is  frequent  and  its 
constant  practice  still  further  brutifies 
the  defective  subject.  The  uncontrolled 
sexual  desire  may  also  lead  to  offenses 
against  morality  in  both  sexes.  Sexual 
perversion  is  not  infrequent, 

There  is  often  a  perversity  of  charac- 
ter, a  collection  of  bad  habits,  which 
make  the  idiot  or  imbecile  an  extremely 
offensive  companion.  He  will  strike 
without  provocation,  spit  at  those  who 
endeavor  to  correct  him,  and  he  seems  to 


have  an  especial  tendency  to  soil  his 
clothing  with  excretal  matters.  It  is 
very  probable  that  these  habits  are  the 
result  of  bad  training,  some  of  them 
being  adopted  as  means  of  defense 
against  those  who  use  the  idiot  as  a  butt 
for  their  miscalled  pleasantries, — un- 
pleasantries  would  seem  the  better  word. 

The  so-called  "moral  idiot"  belongs  to 
the  same  class  with  the  other  idiots. 
While  his  apparently  total  lack  of  regard 
for  the  moral  law  is  the  most  prominent 
of  his  characteristics,  a  careful  examina- 
tion and  consideration  of  his  history  will 
show  that  the  essential  feature  of  his 
malady  'is  weak-mindedness. 

Cretinoid  idiocy  differs  entirely  in  . 
pathology  and  etiology  and  is  treated 
under  another  heading.   (See  Infantile 
Myxcedema,  volume  iii.) 

Diagnosis. — In  the  absence  of  a  history 
of  the  subject  the  only  difficulty  of  diag- 
nosis possible  is  with  consecutive  de- 
mentia. In  advanced  stages  of  this  con- 
dition the  resemblance  to  imbecility  is 
sometimes  great,  but  a  short  period  of 
observation  will  usually  show  points  of 
divergence.  The  malady  of  the  chronic 
dement  is  progressive;  the  symptoms  of 
the  idiot  remain  unchanged. 

The  recognition  of  idiocy  in  early  life 
is  important,  but  the  delay  in  the  normal 
development  of  the  intellectual  powers 
generally  postpones  the  recognition  of 
feeble-mindedness  in  children  until  the 
third  or  fourth  year. 

Prognosis. — The  prognosis  of  idiocy 
and  imbecility,  taking  into  account  the 
pathogeny  of  the  condition,  is  unfavor- 
able. There  is  at  present  no  means 
known  to  medical  science  or  art  by  which 
a  brain  defective  in  structure  or  organiza- 
tion can  be  made  perfect.  But  training 
by  tactful  teachers  in  properly  equipped 
institutions,  and  in  some  cases  of  con- 
tracted skull,  surgical  intervention,  to 


70  INSANITY.    IDIOCY  AND  IMBECILITY.    TREATMENT.  PARANOIA. 


permit  the  brain  to  expand,  have  wrought 
great  improvement.  In  cretinoid  cases 
the  administration  of  thyroid  extract  has 
produced  marked  changes  for  the  better. 
(See  Animal  Extracts,  volume  i.) 

Treatment. — The  treatment  of  feeble- 
mindedness should  be  primarily  prophy- 
lactic. The  irrational  way  in  which 
many  children  are  brought  up  leads 
naturally  to  imbecility.  If  anatomical 
defects  are  at  the  base  of  the  feeble- 
mindedness, no  method  of  treatment 
known  offers  any  chance  of  improvement. 
In  cases  where  premature  synostosis  of 
the  skull  is  certainly  present,  there 
should  be  no  hesitation  to  do  Lan- 
nelongue's  operation  of  craniectomy. 
While  the  results  of  the  operation  to  the 
present  time  have  not  been  generally  en- 
couraging, there  is  sufficient  ground  for 
the  hope  that  some  good  will  result  from 
the  operation  in  properly-selected  cases. 

The  main  reliance  must  be  placed 
upon  good  pedagogic  methods.  The  idiot 
must  be  taken  in  hand  as  early  as  prac- 
ticable by  a  qualified  teacher.  Correct 
habits  must  be  taught  and  their  practice 
enforced  by  constant  supervision.  The 
idiot  must  be  looked  upon  as  an  unfortu- 
nate, and  not  as  a  pervert  with  criminal 
instincts.  Endeavors  must  be  made  to 
lead  him  to  correct  behavior.  It  will  be 
found  usually  much  easier  to  lead  than 
to  drive  him. 

More  benefit  is  to  be  anticipated  from 
training  than  from  operation  in  micro- 
cephalus,  since  the  condition  is  generally 
dependent  on  faulty  intra-uterine  brain- 
development  rather  than  premature  syn- 
ostosis. G.  E.  Shuttlesworth  (Brit.  Med. 
Jour.,  Sept.  28,  '95). 

The  mistake  must  not  be  made  of  ex- 
pecting too  much  from  training  an  idiot. 
The  best  qualified  teacher  cannot  make 
brains.  Tie  can  only  utilize  those  he 
finds  ready  to  hand. 

Group  IT.    Psychoses  due  to  Vi- 


cious or  Abnormal  Brain-organiza- 
tion (Always  Hereditary). 
Paranoia. 

Definition. — A  chronic,  inherited,  in- 
curable form  of  insanity,  generally  pro- 
gressive, characterized  principally  by  hal- 
lucinations and  persistent  delusions,  and 
rarely  terminating  in  dementia. 

The  literal  meaning  of  the  term  para- 
noia is  a  dislocation  or  displacement  of 
the  mind;  the  German  term  is  Verrilkt- 
heit.  In  most  cases  the  intellectual 
powers  are  preserved  and  the  affected 
person  may  reason  with  much  correct- 
ness. His  conclusions  follow  logically 
upon  his  premises,  but  as  these  are 
wrong  the  conclusions  are  likely  to  be 
false.  The  milder  forms  are  generally 
•known  as  cranks.  It  has  become  the 
fashion  to  call  these  persons  degenerates, 
and  to  class  them  with  geniuses,  crim- 
inals, saints,  musicians,  artists,  and  an- 
archists. Obviously  such  an  heterogene- 
ous commingling  of  discordant  elements 
fails  to  make  clear  to  the  ordinary  mind 
what  a  crank  or  paranoiac  really  is. 

Development. — The  person  burdened 
with  an  inherited  neuropathic  tendency 
usually  shows  psychical  evidences  of  it 
in  early  life.  There  is  in  childhood  ex- 
centricity,  abnormal  reserve,  morbid 
pride,  at  times  uncontrollable  anger;  the 
child  is  peculiar,  is  not  like  other  chil- 
dren. At  an  early  age  there  may  be  al- 
ready evidences  that  the  child  regards 
itself  as  ill-treated  by  parents  or  others; 
its  merits  are  minimized,  its  faults  exag- 
gerated. The  other  children  in  the 
family  always  get  more  than  their  share 
of  praise.  This  morbid  sensitiveness, 
usually  baseless,  is  often  accompanied  by 
excessive  precocity.  Prizes  are  gained  in 
school  which  are,  however,  generally  re- 
garded as  entirely  inadequate  rewards  for 
the  tasks  accomplished. 

After  puberty  generally,  sometimes 


INSANITY.    PARANOIA.  SYMPTOMS. 


71 


not  until  after  middle  life,  the  excentrici- 
ties  of  behavior  become  more  marked. 
The  subject  cannot  live  in  peace  and 
amity  with  anyone  for  a  long  time;  he 
develops  hallucinations  and  delusions. 
These  are  generally  present  at  some  stage 
of  the  disease,  although  its  development 
may  stop  short  of  their  production. 

The  hallucinations  and  delusions  dom- 
inate the  thought  and  conduct  of  the 
subject.  As  KrafTt-Ebing  says:  "The 
paranoiac  feels  and  acts  as  if  his  delu- 
sions were  true." 

From  the  twentieth  to  the  fortieth 
years  the  excentricities,  hallucinations, 
and  delusions  either  gradually  or  by  sud- 
den accessions  become  more  marked. 
The  delusions  become  systematized,  as  it 
is  termed.  That  is  to  say,  the  delusions 
assume  a  regular  character,  not  varying 
except  in  increasing  intensity  and  greater 
specialization.  Thus,  a  subject,  fancying 
himself  persecuted  by  the  world  in  gen- 
eral, will  gradually  pick  out  a  person 
whom  he  regards  as  his  especial  perse- 
cutor, to  whom,  or  to  whose  machina- 
tions he  ascribes  all  his  misfortunes,  real 
or  imagined. 

[The  genesis  and  gradual  development 
of  a  delusion  and  hallucinations  are 
beautifully  and  artistically  worked  out 
by  Du  Maurier  in  his  novel,  "Peter  Ibbet- 
son."  Similarly,  but  less  successful  from 
the  stand-point  of  scientific  accuracy,  is 
the  genesis  of  delusions  of  persecution  in 
"The  Statement  of  Stella  Maberly,"  a 
novel  by  F.  Anstey.  In  both  of  these 
books  the  catastrophe,  homicide  by  the 
leading  characters,  is  the  direct  conse- 
quence of  the  domination  of  the  will  by 
hallucinations  and  delusions.  Two  char- 
acters stand  out  prominently  in  the  his- 
tory of  the  world  as  examples  of  para- 
noia; one,  the  Roman  Emperor  Caligula, 
and  the  other  the  Czar,  Ivan  the  Fourth, 
surnamed  the  Terrible.  In  the  graphic 
pages  of  Suetonius  one  can  follow  the 
at  first  gradual  and  then  more  rapid 
development  of  the  delusions  of  grandeur 
and  of  persecution,  together  with  the 


sexual  excentricities  and  the  hallucina- 
tions of  hearing  of  the  imperial  Roman 
madman.      The    historical    data  upon 
which  the  paranoiac  character  of  Ivan  is 
based  are  full  and  well  supported.    It  is, 
however,  in  a  romance,  "Prince  Sere- 
bryam,"  by  Count  Alexis  Tolstoi,  trans- 
lated into  charming  English  by  Jeremiah 
Curtin,  that  the  hallucinations,  the  de- 
lusions of  suspicion  and  persecution,  of 
grandeur,    of    religious    exaltation  are 
traced  with  the  hand  of  a  master.    It  is 
strange  that  the  best  descriptions  of  this 
form  of  insanity  come  to  us  from  the 
hands,  not  of  physicians,  but  of  writers 
of  fiction.    George  H.  Rohe.] 
Symptoms. —  Hallucinations. — 
Among  hallucinations,  those  of  hearing 
are  most  frequent  and  annoying.  They 
may  be  simply  disturbing  noises,  but  are 
usually  recognized  as  distinct  voices  often 
attributed  to  particular  persons.  Earely 
the  character  of  the  hallucinations  is 
pleasant  and  agreeable;  much  more  fre- 
quently they  are  irritating.   Thus,  in  the 
most  frequent  form  of  the  auditory  hal- 
lucinations the  subject  hears  persons 
accuse  him  of  dishonesty  or  other  im- 
proper practices,  persons  call  him  oppro- 
brious names,  or  he  hears  conversations 
which  reflect  upon  him  in  various  ways. 
Under  the  influence  of  these  hallucina- 
tions the  patient  may  make  complaint  to 
the  suspected  person,  or  invoke  the  aid 
of  the  law  to  right  what  the  patient  con- 
siders wrongs  done  him.    When  these 
measures  fail,  the  patient  may  take  the 
law  into  his  own  hands  and  endeavor  to 
right  the  wrongs  himself. 

[Thus,  a  young  man  of  fair  education, 
and*  who  was  in  all  respects  an  excellent 
clerk,  fancied  he  heard  his  employer  re- 
flect upon  his  honesty.  He  complained 
to  the  employer  of  the  supposed  injustice 
and  was  informed  that  he  was  entirely 
mistaken  and  that,  on  the  contrary,  his 
services  were  very  satisfactory.  This 
quieted  him  for  a  time,  when  the  voices 
returned.  He  then  resigned  his  position 
and  spent  his  time  at  his  home  brooding 
over  his  troubles.    In  the  meantime  the 


INSANITY.    PARANOIA.  SYMPTOMS. 


hallucinations  continuing,  he  purchased 
a  revolver  and  spoke  to  some  members 
of  his  family  of  the  persecutions  to  which 
he  was  subjected  to  by  his  former  em- 
ployer. Finally,  one  day  he  went  to  the 
latter's  house,  and  calling  him  to  the 
door,  fired  at  him,  fortunately  without 
doing  any  injury.  Being  arrested,  his 
references  to  his  hallucinations  and  de- 
lusions resulted  in  his  being  committed 
as  insane.  For  months  his  conduct  in 
the  institution  was  extremely  precise; 
he  was  quiet  and  well  behaved,  and  in 
conversation  refused  to  acknowledge  the 
presence  of  hallucinations  and  delusions. 
In  his  correspondence  with  members  of 
his  family,  however,  the  persistence  of 
both  was  manifest.  In  another  case, 
boys  followed  the  patient  in  the  street, 
shouting  opprobrious  epithets.  He  also 
had  hallucinations  of  smell  and  taste, 
with  delusions  of  poisoning.  In  another 
case,  a  woman  (spinster),  hallucinations 
of  hearing  were  combined  with  those  of 
smell  and  sight.  A  sexual  tendency  was 
manifest  in  the  hallucinations,  although 
the  behavior  of  the  patient  was  unex- 
ceptionable. Male  attendants  in  the 
hospital,  and  sometimes  visitors,  would 
shout  obscene  remarks  at  her  during  the 
night.  These  were  usually  attributed  to 
the  most  circumspect  persons.  On  one 
occasion  a  high  ecclesiastical  dignitary 
visited  the  hospital,  and  a  few  days  later 
the  patient  complained  that  she  had  been 
compelled  to  endure  his  presence  and  em- 
braces during  the  previous  night.  Simi- 
lar complaints,  with  no  more  reason, 
were  made  against  some  of  the  attend- 
ants. She  imagined  a  machine  by  which 
obscene  pictures  were  thrown  on  the 
walls  of  her  room  during  the  night  which 
she  was  compelled  to  look  at.  These 
frequently  kept  her  awake,  she  averred, 
during  the  greater  part  of  the  night.  At 
table  some  of  the  attendants  delighted 
in  throwing  a  stream  of  putrid  sewage 
from  a  hose  between  her  plate  and  her 
mouth,  so  that  she  was  prevented  from 
eating.  The  latter  behavior,  which  she 
regarded  as  particularly  atrocious,  was 
generally  attributed  to  the  women  nurses 
in  her  ward.  In  other  respects  she  was 
an  extremely  well  conducted  patient,  an 
exceptionally  good  and  industrious  seam- 


stress, and  painfully  neat  and  clean 
about  her  person,  clothing,  and  room. 
George  H.  Roue.] 

Hallucinations  of  vision  are  often  of  a 
pleasurable  character.  The  visions,  so 
graphically  described  by  Du  Maurier  in 
the  novel  before  mentioned  are  examples. 
On  the  other  hand,  the  visions  may  be 
disturbing  or  terrifying  and  aid  in  the 
genesis  of  delusions  of  suspicion  or  perse- 
cution. 

Delusions. — Delusions  are  usually 
evolved  out  of  hallucinations,  although 
they  may  originate  independently  of 
these.  In  paranoia  the  characteristic  de- 
lusions are  those  of  persecution,  com- 
bined with  delusions  of  grandeur.  There 
are  also  delusions  of  personality,  where 
the  subject  fancies  himself  another  per- 
son,— usually  one  belonging  to  a  higher 
social  caste.  Among  the  delusions  be- 
coming rather  frequent  at  the  present 
time  are  those  of  electrical  and  hypnotic 
influence  and  of  thought  reading.  The 
electrical  delusions  are  sometimes  very 
complicated.  The  patient  is  controlled 
by  a  dynamo,  or  some  modification  of  the 
telephone,  which  is  in  the  office  of  the 
chief  of  police  of  the  city.  Through  this 
the  patient  is  annoyed  by  tlje  police,  the 
detectives,  or  corrupt  politicians,  whose 
names  are  mentioned  by  the  patient  with 
great  freedom.  When  the  patient  wants 
to  bring  his  complaints  before  the  proper 
authority,  the  persecutor  brings  the 
machine  into  play  and  confuses  the  pa- 
tient's mind  or  words  to  the  extent  that 
he  cannot  make  an  intelligent  verbal 
complaint.  He  usually  gives  his  com- 
plaint very  extensively  and  often  con- 
nectedly in  writing.  The  electrical  or 
hypnotic  apparatus  is  also  used  to  deprive 
the  patient  of  sexual  power,  or  to  compel 
him  to  masturbation,  which  he  regards 
as  an  attack  upon  his  self-respect.  If  one 
does  not  believe  his  words  it  is  easy  to 


An  Ever  Important  Subject 


A  SECOND,  REVISED,  AND  ENLARGED  EDITION  OF 

DISEASES 

of  the 

Ear,  lose  u  Throat 

and 

THEIR  ACCESSORY  CAVITIES. 


BY 


SETH  SCOTT  BISHOP,  M.D.,  D.C.L.,  LL.D., 

Professor  of  Diseases  of  the  Nose,  Throat,  and  Ear  in  the  Illinois  Medical 
College  ;  Professor  in  the  Chicago  Post-Graduate  Medical  School 
and  Hospital ;  Surgeon  to  the  Post-Graduate  Hospital ; 
one  of  the  Editors  of  the  "  Laryngoscope,"  etc. 


Illustrated  with  Ninety-four  Colored  Lithographs 
and  Two  Hundred  and  Fifteen  Half-tones  and 
Photo-engravings. 


554  Pages,  Royal  Octavo.    Prices:    In  Extra  Cloth, 
$4.00  net;   Sheep  or  Half-Russia,  $5.00  net. 
Delivered  free  of  express  or  mail  charges. 


During  a  large  part  of  the  year  a  physician's  daily 
routine  has  to  do  with  the  conditions  forming  the 
subjects  of  this  book.  The  primary  disease  and  its 
sequela  constitute  a  large  percentage  of  the  direct 


causes  of  death,  not  to  speak  of  the  enormous  amount 
of  incidental  discomfort.  For  this  reason  a  text-book 
presenting  the  rational  and  conservative  methods  of 
treatment  recommended  by  the  leading  authorities  in 
these  respective  departments  can  always  he  expected 
to  have  a  place  in  the  up-to-date  library. 

A  very  large  first  edition  was  distributed  in  a 
little  over  a  year,  but  with  the  revision  there  seems 
to  be  a  likelihood  that  all  previous  records  will  be 
broken.  New  type,  new  illustrations,  new  complete 
chapters,  and  the  addition  of  new  material  through- 
out, increasing  the  reading  matter  more  than  thirty 
(30)  per  cent.,  seems  to  have  convinced  all  who  have 
seen  the  new  edition  that  it  now  stands  without  an 
equal  as  the  ideal  practical  treatise  on  this  branch  of 
Medical  Science. 

The  subject  of  the  "ear"  has  long  been  classi- 
fied with  the  "  EYE,"  to  which  it  bears  a  compara- 
tively slight  relation.  Expressions  of  gratitude  are 
heard  on  every  hand,  that  Dr.  Bishop  should  have 
brought  about  a  more  practical  and  appropriate  asso- 
ciation. Physicians  will  find  the  new  arrangement 
very  practical,  and,  considering  the  low  price  at  which 
the  book  is  sold,  can  well  afford  to  have  the  latest 
and  best  in  these  three  departments. 

The  contents  of  the  work  are  divided  as  follows:— 
PART  I.— Diseases  of  the  Ear. 

1  A  General  Consideration  of  Diseases  of  the  Ear,  Nose 
and  Throat  Based  on  aStudv  of  Twenty-one  Thousand 
Cases. 

II.  Examination  of  Patients. 

III.  Compressed-Air  Appliances  and  their  Uses. 

IV.  Methods  of  Producing  and    Using  Compressed 

Air. 

V.  Diseases  of  the  External  Ear. 

VI.  Diseases  of  the  External  Auditory  Canal. 


VII  to  XII.  Diseases  ot  the  Middle  Ear. 

XIII.  Extension   of    Ear   Diseases   to   the  Cranial 
Cavity. 

XIV.  Diseases  of  the  Mastoid  Process. 

XV.  The  Mastoid  Operations. 

XVI  to  XVII.  Diseases  of  the  Internal  Ear. 

PART  II.— Diseases  of  the  Nose. 

XVIII.  Examination  and  Instruments. 

XIX  to  XXIV.  Diseases  of  the  Nasal  Cavities. 

XXV.  Diseases  of  the  Accessory  Cavities  of  the  Nose. 

XXVI.  Related  Diseases  of  the  Eye  and  Nose. 

XXVII.  Diseases  of  the  Naso-Pharyngeal  Cavity. 

PART  III.-XXVIII  to  XXXIV.  Diseases  of 
the  Pharynx. 

PART  IV.— Diseases  of  the  Larynx. 

XXXVI  to  XLIII.  Diseases  of  the  Larynx. 

XLIV^  Life-insurance  Affected  by  Diseases  of  the 

Ear,  Nose,  and  Throat. 
An  Appendix  Comprising  Remedies  (a  valuable  list 

ot  Formulae),  and  a  Case-record  Book. 


A  Thoroughly  Complete  and  Convenient  Index 
Concludes  the  Volume. 


The  following  reviews  of  the  first  edition  may 
prove  interesting:— 

with  tot^^g^^ij^**  ?par field 

study  in  these  lines    ,  f  '"\  a  desire  for 

?ral  practitioner  wil  fi  'a  f  hffftuffiff  i,he SeU' 
pal  P urpuses,  and  the  special  st  '  ,  [ 'ff  t (lt',  toI\al1  P™cti- 
Mterested  in  its  contend  as  it  is  '  r  to-,)e  tll0J0ughly 
valuable  suggestions  for  M^Si'^ 

Lciamef  whicn  are  emhSed^^F^"!  °f  the  »™e 
patulate  the  author  ™onh^  nS  ™lume'  we  Con" 
|ul  condensed  view  ofPthp  Ki^J^S^  most  success- 
h*d.-Therapmtic  J«2«etl  eatmont  °f  affecti™s  of  the 


S„ch  a  book  as  the  one  before  us  shows 


Such  a  booK  as  tne  one  ,  "  "    author  who 

and  attractive  a  subject  may  be  made  ^y  an  JJ^8^t 
thoroughly  understands i  it  hinacM, .and :  £no  na  fc 
practical  dealings  with  it.  We  d°  jot  *n°w  ^  and  throat, 
on  the  specialty  of  the  peases  of  ^  >_ 

On  the  whole,  the  work  is  well  ^^^SK^nd 
the  end  the  author  had  m t  view -    It ^lYtivl  tSfoVncies 
care  in  preparation,  and  from  its  conse "a«»e 
should  have  a  good  influence  upon  th «  ^elV/fC  (SnS 
the  phvsician  who  may  add  it  to  his  liDrary. 
dian  Practitioner. 

The  work  before  us  is  a  most  excellent  one  magnifi- 

-II L  iouia  J^dicai  and  Surgical  Journal. 

rrn..\a  worv  deserves  recommendation  because  of  its 
Up-toSSrha"and  timely  ^r^on  of  recently 

We  cannot  say  too  much  in  praise  of  this  work.- 
Australasian  Medical  Gazette. 

This  is  a  most  complete  and  illustrated  monograph  of 

these  important  organs  of  the  body.  We  rewind  in  the 
»r^e„^ffl^^-X»^ 
Homcepathic  Review  (Calcutta,  India). 

The  new  edition  contains  the  following  new 

chapters: — 

.Related  Diseases  of  the  Eye  and  Nose,'  and 
aTJfe-insurance  Affected  by  Diseases  of   the  Ear, 
Nose   and  Throat."    The  Subjects  of  « Autoscopy 
and  I.  PachTdermia  Earyngis"  are   also  fully  con- 
sidered. 


THE  F.  A.  DAVIS  CO.,  Publishers. 

PHILADELPHIA :  1914-16  Cherry  Street. 

NEW  YORK:  117  W.  Forty-second  Street. 

CHICAGO:  9  Lakeside  Building,  214-220  S.  Clark  St. 

1 1  X — <w 


INSANITY.  PARANOIA. 


SYMPTOMS.  DIAGNOSIS. 


73 


prove  it  absolutely  by  a  galvanometer 
which  if  attached  to  his  head  will  show 
the  presence  of  an  electric  current.  A 
similar  machine, — the  description  given 
is  usually  very  vague, — is  used  to  detect 
the  patient's  thoughts,  and  so  get  him 
into  trouble. 

[One  patient,  a  woman,  who  was  very 
much  disturbed  by  the  use  of  such  a 
machine  by  the  writer,  invented  one  to 
counteract  the  influence  of  the  first.  Of 
course,  the  machine  was  never  actually 
constructed;  it  existed  only  in  the  pa- 
tient's mind.    George  H.  Rohe.] 

Under  the  influence  of  delusions  of 
persecution,  the  patients  themselves  be- 
come persecutors:  the  persecuteurs  per- 
secutes of  French  authors.  To  this  class 
belonged  Guiteau  and  Prendergast,  the 
assassins  of  President  Garfield  and  Mayor 
Carter  Harrison,  whose  history  is  so  re- 
cent that  no  detailed  reference  is  here 
needed. 

The  delusions  of  grandeur  may  be 
present  with  or  without  hallucinations. 
They  are  usually  combined  with  delu- 
sions of  persecution,  although  these  may 
be  in  temporary  abeyance.  Thus,  the 
asylum  princes,  saints,  great  generals,  or 
even  deities,  while  protesting  their  high 
estate,  lament  the  fact  that  through  the 
villany  of  others  they  are  deprived  of 
their  just  rights.  These  persons  are  also 
dangerous,  because  they  sometimes  seek 
to  obtain  by  force  the  honors  of  which 
the  world  has  robbed  them. 

Literature  of  '96-'97-'98. 

In  the  early  stages  of  paranoiac  dis- 
ease the  delusions  relate  to  some  en- 
croachments upon  the  life,  health,  honor, 
or  property  of  the  patient.  Such  pa- 
tients are  usually  self-centered,  and  from 
childhood  have  been  reserved,  suspicious, 
and  often  hypochondriacal.  They  are 
generally  badly  developed,  and  have  the 
more  common  stigmata  of  degeneracy:  as 
a  want  of  symmetry  of  both  sides  of  the 


face,  a  lack  of  development  of  facial 
bones,  giving  rise  to  the  protruding  chin 
and  "whopper"  jaw  so  characteristic  of 
the  descendants  of  the  Emperor  Charles 
V,  or  asymmetrical  palpebral  fissures. 
They  are  generally  unduly  responsive  to 
all  external  disturbing  influences,  and 
the  development  of  morbid  characteris- 
tics may  follow  comparatively  slight  dis- 
turbing causes.  Paranoia  develops  as  an 
unmistakable  disease  when  hallucina- 
tions of  the  special  senses  give  rise  to 
actual  delusions.  The  delusions  are  at 
first,  and  often  for  many  years,  those  of 
persecution,  and  their  character  is  deter- 
mined by  their  habits  of  life,  system  of 
beliefs,  and  above  all  by  their  antecedent 
mental  development  or  education.  They 
believe  the  world  to  be  generally  un- 
friendly to  them  and  seclude  themselves 
from  their  fellows. 

Sooner  or  later,  however,  they  are 
forced  by  vividness  of  their  hallucina- 
tions to  defy  their  enemies,  and  then  de- 
velop dangerous  tendencies.  Most  of  the 
crimes  committed  by  the  paranoiacs  are 
done  at  this  stage  of  their  disease.  The 
terminal  state  of  paranoia  is  what  has 
been  happily  termed  by  one  writer  the 
stage  of  transformation  by  which 
through  a  further  elaboration  of  his  de- 
lusions the  patient  finally  believes  he  has 
solved  the  terrible  secret  which  has 
hitherto  clouded  his  whole  life.  He  be- 
gins to  believe  that  he  is  persecuted  be- 
cause he  is  a  superior  being,  and  delu- 
sions of  grandeur,  power,  and  impor- 
tance replace  those  of  persecution;  so 
that,  though  he  may  suffer,  still  he  re- 
joices more  than  he  suffers. 

Every  case  of  developed  paranoia 
should  be  under  custody  and  control 
until  such  time  as  the  stage  of  transfor- 
mation occurs.  Henry  M.  Hurd  (Nash- 
ville Jour,  of  Med.  and  Surg.,  May,  '96). 

Diagnosis. — The  history  of  a  neuro- 
pathic ancestry,  the  slow  development, 
the  persistent  character  of  hallucinations 
and  delusions,  with  the  comparatively 
slight  degree  and  late  appearance  of  de- 
mentia differentiate  paranoia  from  other 
forms  of  insanity.  At  times  moderate 
grades  of  imbecility  may  simulate  para- 


74 


INSANITY.  PARANOIA. 


RECURRENT  INSANITY. 


noia,  but  careful  observation  for  a  time 
will  usually  permit  a  definite  diagnosis. 

Four  cases  of  chronic  paranoia,  show- 
ing degeneration  of  posterior  cords  of 
spinal  marrow.  Alterations  of  spinal  cord 
in  relation  with  psychical  troubles  of 
paranoia.  Bernhard  Feist  (Virchow's 
Archiv,  B.  138,  H.  3,  '95). 

Prognosis. — As  stated  in  the  definition, 
paranoia  is  incurable.  Krafft-Ebing  says 
that  in  over  one  thousand  cases  under 
personal  observation  not  a  single  recovery 
resulted.  Kemissions,  and  prolonged  in- 
termissions for  a  year  or  more  may  occur. 
These  may  be  true  lucid  intervals  with 
disappearance  of  all  symptoms,  but 
should  not  be  regarded  as  permanent  re- 
coveries. 

The  duration  of  life  is  not  shortened 
by  paranoia.  Dementia  is  not  likely  to 
occur  until  late  stages,  and  then  usually 
only  to  a  moderate  degree.  Slightly 
marked  weak-mindedness  is,  however, 
not  unusual. 

Treatment. — The  paranoiac  is  always 
potentially  a  dangerous  character,  and 
hence  requires  to  be  kept  under  observa- 
tion when  the  diagnosis  is  established. 
The  restriction  of  a  person's  liberty  is  not 
to  be  lightly  advised,  but  the  advice  is 
rarely  improper  in  this  form  of  insanity. 
The  paranoiac  is  usually  much  better  in 
an  institution  for  the  insane  than  when 
at  large.  His  hallucinations  and  delu- 
sions become  less  disturbing,  and  he  is 
largely  deprived  of  the  power  of  mischief. 
There  are  no  "harmless  cranks."  They 
may  be  too  cowardly  to  commit  overt 
acts,  but  the  fact  that  most  of  these 
characters  when  admitted  to  hospitals  are 
armed  with  loaded  revolvers  or  other 
concealed  weapons  is  an  indication  of  the 
trend  of  their  thoughts.  In  all  cases  of 
paranoia  the  patient  should  be  placed 
under  strict  observation  and  control. 
There  is  no  other  safe  treatment. 


The  paranoiac  is  a  menace  to  society 
and  should  be  sequestrated.  C.  B.  Burr 
(Medicine,  Nov.,  '95). 

Recurrent  Insanity. 
Definition. — Recurrent  or  periodic  in- 
sanity appears  as  states  of  exaltation 
(mania),  depression  (melancholia),  or  an 
alternation  of  the  two  (circular  insanity), 
with  intervals  of  apparent  lucidity.  Peri- 
odic dipsomania  is  one  form  of  recurrent 
insanity.  The  tendency  to  recur  persists 
throughout  life,  and  dementia  is  rare. 

Recurrent  Mania. —  Symptoms. — The 
essential  feature  of  recurrent  mania  is  the 
occurrence  of  exaltation  of  feelings  with- 
out confusion  of  ideas.  The  usual  symp- 
toms of  mania  (q.  v.)  probably  dependent 
upon  cerebral  hyperemia  come  on  often 
without  any  prodromic  symptoms  of  de- 
pression. After  a  month  or  longer  in  the 
exalted  stage,  the  patient  gradually, 
sometimes  suddenly,  returns  to  his  nor- 
mal mental  condition,  which,  however,  is 
not  to  be  mistaken  for  recovery.  The 
victim  of  periodic  insanity  exhibits  even 
in  the  intervals  evidences  of  some  in- 
volvement of  the  intellectual  functions. 
The  inherited  tendency  to  mental  dis- 
turbance is  always  discoverable. 

'[I  recall  a  well  marked  case  in  a  phy- 
sician of  about  55  years  of  age.  He  had 
been  insane  five  or  six  times  before.  The 
first  symptoms  of  an  attack  were  neglect 
of  his  patients  and  an  exceptional  in- 
terest in  the  religious  life  of  his  neigh- 
bors. He  talked  religion  and  dialectics 
to  anyone  who  would  listen  to  him.  As 
the  malady  advanced  he  began  to  regard 
himself  as  a  fountain  of  medical  knowl- 
edge, capable  of  filling  any  chair  in  any 
college  to  which  he  might  be  called.  He 
had  proposed  himself  for  any  vacancy 
that  might  occur  in  one  of  the  medical 
colleges  of  Baltimore.  The  branch  to  be 
taught  did  not  matter  to  him:  be  was 
equally  competent  in  all.  George  H. 
ROHE.] 

During  the  attack  there  is  usually 
some  loss  of  weight.    The  first  attack 


INSANITY.    RECURRENT  MELANCHOLIA.    CIRCULAR  INSANITY. 


75 


most  frequently  occurs  at  puberty.  In 
women  succeeding  attacks  often  coincide 
with  the  menstrual  period. 

Psychical  integrity  of  women  during 
their  menses  is  a  question  most  useful 
to  consider  in  legal  medicine.  It  appears 
expedient  to  find  out  if  the  crime  com- 
mitted by  the  prisoner  coincided  with 
her  menstrual  period.  Under  the  term 
"period"  is  included  not  only  the  days 
during  which  the  blood  comes  away,  but 
those  that  precede  and  follow  it. 

An  examination  of  the  mental  condi- 
tion should  be  advised  when  the  criminal 
act  coincides  with  this  period.  This  ex- 
amination is  indispensable  when  the  his- 
tory of  the  patient  reveals  a  neuropathic 
taint  or  the  existence  of  mental  trouble 
during  former  menstrual  periods,  or 
when  the  act  itself  discloses  peculiar 
changes. 

When  it  is  evident  that  the  menstrual 
process  exercised  a  powerful  influence  on 
the  mental  life  of  subject,  she  should 
have  the  benefit  of  this  fact,  even  if  no 
menstrual  insanity  can  be  made  out  in 
what  concerns  the  application  of  the  law 
in  the  given  case.  Krafft-Ebing  (Jahr- 
buch  fiir  Psych.,  vol.  x;  Annals  of  Gyn. 
and  Psed.,  June,  '94). 

Pbognosis. —  Permanent  restoration 
of  normal  mental  function  does  not 
occur.  Individual  attacks  are,  however, 
recovered  from  and  the  patient  remains 
apparently  well  until  the  next  outbreak. 
The  intervals  between  attacks  may  be 
weeks,  months,  or  years.  In  one  case  now 
under  observation  the  intervals  are  about 
two  weeks. 

Dementia  is  rare. 

Tkeatment. — Chloral  and  bromide  of 
potassium  may  be  given  to  depress  the 
circulation  and  cerebral  exaltation. 
Krafft-Ebing  recommends  large  doses  of 
morphine  at  the  beginning  of  the  attack. 
In  my  hands  sulphonal  has  given  the  best 
results.  Fifteen  to  20  grains  are  given 
every  four  hours  and  the  quantity  rapidly 
reduced  as  the  maniacal  condition  passes 
away.   In  most  cases  the  drug  can  be  re- 


duced to  5  or  even  3  grains  at  a  dose  in 
the  course  of  three  or  four  days.  The 
effects  of  the  remedy  upon  the  kidneys 
should  be  carefully  watched.  Bed-rest, 
baths,  and  good  feeding  are  essentials  in 
the  treatment  equally  as  important  as 
medicinal  agents. 

Recurrent  Melancholia. — The  symp- 
toms are  usually  those  of  simple  melan- 
cholia without  delusions;  the  attacks 
come  on  rapidly,  and  after  a  duration  of 
some  weeks  or  months  disappear  as 
quickly.  Here  is  profound  depression, 
loss  of  appetite,  headache,  and  insomnia. 

Prognosis. — Favorable,  so  far  as  the 
individual  attacks  are  concerned,  but  per- 
manent recovery  does  not  occur. 

Tkeatment. — The  favorable  effects  of 
opium  as  manifested  in  ordinary  melan- 
cholia are  not  so  pronounced  in  the  re- 
current variety.  Krafft-Ebing  recom- 
mends the  following  for  its  ameliorating 
effects: — 

1^  Sodii  bromidi,  oiiss. 
Antipyrini,  gr.  xlv. 
Codeini  hydrochlorat.,  gr.  v. 
Aquae  destill.,  giv. 
Syr.  menthae  pip.,  ov. 
M.    Sig.:  One  teaspoonful,  gradually 
increased  to  7  teaspoonfuls  as  required, 
twice  a  day. 

Circular  Insanity  (Alternating  In- 
sanity) . 

Definition. — A  form  of  insanity  in 
which  states  of  mania  and  melancholia 
alternate  with  each  other  with  or  without 
lucid  intervals'  intervening. 

Symptoms.— The  disease  may  begin 
with  mania  or  melancholia.  The  initial 
mental  disturbance,  of  variable  duration, 
is  followed,  either  directly  or  after  a  lucid 
interval,  by  the  opposite  condition.  The 
duration  of  the  cycle  may  be  weeks, 
months,  or  years.    In  some  cases  there 


76 


INSANITY.  MELANCHOLIA. 


are  marked  delusions.  The  maniacal 
stage  is  usually  one  of  simple  exaltation. 

Diagnosis. — This  is  only  possible 
after  prolonged  observation  or  when  a 
trustworthy  history  of  previous  attacks 
can  be  obtained.  Cases  with  lucid  inter- 
vals between  the  stages  of  depression  and 
exaltation  are  rare. 

Prognosis.  —  This  is  unfavorable. 
The  duration  of  the  disease  is  for  life. 
Dementia  does  not  occur  except  in  ad- 
vanced stages.  The  exhaustion  of  the 
maniacal  stage  may  shorten  life. 

Treatment. — The  treatment  is  un- 
satisfactory. Chloral  fails  to  quiet  the 
exaltation  and  restlessness  in  the  mani- 
acal stage  unless  given  in  such  doses  as  to 
be  dangerous.  In  like  manner,  opium  is 
usually  of  little  benefit  durjng  the  stage 
of  depression.  When  possible,  rest  in 
bed  should  be  enforced,  especially  in  the 
stage  of  excitement. 

Dipsomania. — Definition. — A  mor- 
bid irresistible  desire  for  intoxicating 
liquors. 

Ordinary  indulgence  in  alcoholic 
liquors  must  not  be  considered  as  dipso- 
mania; neither  are  the  various  forms  of 
drug-habit  to  be  grouped  with  it.  These 
habits  are  formed  by  repeated  indul- 
gence, which  in  the  early  stages  can  be 
avoided  by  the  exercise  of  a  little  re- 
straint. In  dipsomania,  on  the  other 
hand,  the  impulse  that  drives  the  sub- 
ject to  drink  is  due  to  an  inherited  neuro- 
pathic tendency  which  is  too  strong  to  be 
resisted  when  the  opportunity  to  indul- 
gence offers. 

In  a  case  known  to  me,  a  prominent 
public  man  of  fine  domestic  attributes, 
intelligent,  strong-willed,  a  man  known 
to  the  public  as  a  leader  or  "boss,"  the 
desire  would  arise  suddenly.  He  would 
attend  political  gatherings  and  banquets, 
would  work  out  with  his  confreres  the 
problems  of  carrying  a  district,  or  in- 
fluencing a  legislative  body,  and  all  the 


time  refuse  to  take  a  drink.  On  the  way 
home,  in  a  car  or  carriage,  he  would  pass 
a  drinking-saloon;  if  a  low  or  dis- 
reputable one  it  appeared  more  attrac- 
tive; he  would  stop,  enter  and  take  a 
drink,  which  generally  resulted  in  a  pro- 
longed debauch  ending  with  an  attack 
of  mania  a  potu.  In  all  this  there  was 
no  pleasure  in  the  indulgence.  He  was 
fully  conscious  of  the  degradation  to 
which  he  subjected  himself  and  his 
family.  He  had  been  repeatedly  warned, 
both  by  his  physicians  and  by  his  polit- 
ical friends  who  were  interested  in  his 
supremacy,  that  continued  indulgence 
would  be  dangerous,  not  only  to  his 
temporal  prospects,  but  to  his  life.  To 
all  remonstrances  he  turned  a  deaf  ear, 
and  finally  died  in  one  of  his  debauches. 
George  H.  Roue.] 

Prognosis. — The  prognosis  of  these 
cases  is  unfavorable.  While  drunkards 
may  reform  and  opium  and  cocaine 
habitues  relinquish  their  stimulus,  the 
dipsomaniac  is  never  cured  of  his  morbid 
appetite. 

Treatment. — This  can  only  be  symp- 
tomatic. Seclusion,  withdrawal  of  alco- 
hol, and  in  the  event  of  delirium  tremens, 
hypnotics,  bed-rest,  and  food  comprise 
the  resources  at  command. 

Psychoneuroses. — It  is  probable  that 
the  brain-organization  in  hereditary  hys- 
teria, hystero-epilepsy,  and  epilepsy  is 
also  primarily  defective.  The  ultimate 
mental  weakness  in  these  states  is,  how- 
ever, a  form  of  secondary  dementia,  prob- 
ably due  to  the  repeated  physical  shocks 
to  which  the  brain  is  subjected  in  the 
nervous  explosions  characterizing  hys- 
teria and  epilepsy. 

Grout  III.  Psychoses  due  to 
Simple  Disturbance  of  Nutrition 
(Anjemia  and  Hyperemia)  of  the 
Brain. 

Melancholia. 

Definition.— Melancholia  is  a  form  of 
mental  disturbance  characterized  by  pro- 


INSANITY.    MELANCHOLIA.  SYMPTOMS. 


7T 


found  mental  depression  with  suicidal 
tendencies.  Its  physical  basis  is  sup- 
posed to  be  anaemia  of  the  brain. 

Symptoms. — The  symptoms  of  melan- 
cholia are  physical  and  mental. 

First  in  importance  are  those  refer- 
able to  the  digestive  organs.  There  is 
nearly  always  profound  anorexia,  often 
resulting  in  obstinate  refusal  to  take 
food.  This  may  be  due  to  gastric  dis- 
turbance, but  is  more  frequently  the 
consequence  of  visceral  hallucinations 
and  delusions  which  will  be  referred  to 
later.  The  tongue  is  usually  coated  and 
the  breath  offensive.  Constipation  is 
nearly  always  present. 

Involuntary  defecation  is  frequent, 
not  because  the  patient  has  lost  control 
over  the  sphincters,  but  on  account  of 
inattention  to  the  sense  of  fullness  in 
the  rectum. 

In  women  there  is  usually  arrest  of 
menstruation.  The  urine  is  generally 
somewhat  diminished  in  quantity  and 
rich  in  phosphates. 

Urine  of  melancholies  is  much  more 
toxic  than  normal  urine;  that  of  maniacs 
is  less  toxic.  Brugia  (Jour,  de  Med., 
Feb.  12,  '93). 

The  toxicity  of  the  urine  was  found 
to  be  diminished  in  maniacal  states  and 
augmented  in  melancholia.  The  urine 
of  maniacal  patients,  when  injected  into 
animals  produces  excitation  and  convul- 
sions; that  of  melancholic  patients,  rest- 
lessness, dejection,  and  stupor.  There  is 
often  in  insanity,  as  in  eclampsia,  an  in- 
verse relation  between  the  toxicity  of  the 
urine  and  that  of  the  blood,  the  latter 
being  hypotoxic  when  the  urine  is  hyper- 
toxic  and  vice  versa.  Regis  (Le  Bull. 
Med.,  Aug.  6,  '93). 

Sexual  desire  is  usually  diminished. 
In  nearly  all,  perhaps  in  all,  cases  of 
melancholia  there  is  depression  of  nutri- 
tion.  The  red  blood-corpuscles  and  the 
percentage  of  haemoglobin  are  reduced. 
Results  of  examination  of  the  blood  in 
fifty-two  patients.     In  mania  the  cor- 


puscles and  haemoglobin  were  normal  or 
in  excess  in  nearly  all  cases.  In  melan- 
cholia the  haemoglobin  was  deficient  in 
all  examined,  and  the  corpuscles  below 
normal  in  50  per  cent.  In  paresis  and  de- 
mentia, corpuscles  and  haemoglobin  were 
deficient.  In  paranoia  the  corpuscles 
were  much  above  the  normal,  while  the 
haemoglobin  was  only  slightly  below. 
J.  A.  Houston  (Boston  Med.  and  Surg. 
Jour.,  Jan.  18,  '94). 

There  is  usually  considerable  loss  of 
weight.  The  skin  is  usually  dry  and 
harsh. 

The  force  of  the  circulation  is  dimin- 
ished. There  is  usually  passive  conges- 
tion of  the  blood-vessels. 

Literature  of  '96-'97-'98. 

The  blood-pressure  varies  in  different 
forms  of  insanity;  it  is  raised  in  persons 
who  are  depressed  and  who  are  suffering 
from  melancholia;  it  varies  in  cases  of 
so-called  agitated  melancholia;  it  is  nor- 
mal upon  the  recovery  of  a  patient  whose 
blood-pressure  has  been  raised  during 
the  period  of  depression;  it  is  lowered 
in  persons  suffering  from  excitement  or 
acute  mania;  it  is  normal  after  the  ex- 
citement has  passed  off  and  the  patient 
has  recovered;  it  tends  to  fall  as  the 
day  advances,  causing  melancholiacs  to 
be  brighter  and  excited  patients  to  be- 
come more  excited;  the  depression  fol- 
lowing upon  an  attack  of  acute  mania  is 
not  necessarily  an  active  depression,  but 
rather  more  exhaustive  in  type,  and  the 
blood-pressure  in  these  cases  may  remain 
low  until  it  finally  returns  to  normal 
upon  recovery;  the  blood-pressure  is 
probably  raised  in  stupor;  it  is  not  al- 
ways altered  in  delusional  insanity  ex- 
cept when  there  is  also  some  emotional 
disturbance;  in  healthy,  active,  and  ex- 
citable persons  it  is  low  as  compared 
with  healthy  apathetic  individuals;  the 
blood-pressure  is  raised  in  general  paraly- 
sis of  the  insane  when  there  is  depres- 
sion, while  in  the  excited  types  of  this 
disease  it  is  low,  as  it  is  also  in  the  later 
stages  of  all  types;  the  feeling  of  weight 
and  pressure  upon  the  top  of  the  head 
is  apparently  vascular  in  origin,  and  is 
lessened  or  disappears  when  the  blood- 


78 


INSANITY.    MELANCHOLIA.  SYMPTOMS. 


pressure  is  lowered.  Maurice  Craig  (Lan- 
cet, June  25,  '98). 
Mental  Symptoms.  —  The  mental 
symptoms  of  melancholia  are  depression, 
hallucinations  and  illusions,  delusions, 
fear  of  death,  and  tendency  to  suicide. 
The  last-named  is  potentially  present  in 
all  cases,  but  is  active  in  many. 

In  simple  melancholia  there  is  pro- 
found depression,  with  a  fear  of  never 
recovering  either  physical  or  mental 
health.  In  these  cases  the  memory  and 
judgment  are  usually  preserved,  but  the 
patient  is  so  entirely  under  the  control 
of  the  depressive  emotion  that  he  cannot 
think  normally. 

In  melancholia  with  delusions,  the 
latter  are  usually  those  of  self-accusa- 
tion, self-abasement,  or  of  justifiable 
persecution.  The  melancholiac  feels 
that  he  is  justly  punished  by  God  for 
some  transgression,  real  or  imagined. 
Indeed,  he  fancies  usually  that  his  pun- 
ishment is  entirely  inadequate  to  the 
transgression. 

The  melancholiac  seeks  death  either 
because  he  thinks  he  merits  it,  or — and 
this  is  perhaps  more  frequently  the  case 
— to  escape  from  mental  distress,  which 
becomes  unbearable. 

[A  patient  of  mine,  who  had  set  fire 
to  her  clothing  and  thus  attempted  to 
destroy  herself,  gave  as  an  excuse  that 
"the  devil  was  after  her  and  she  tried 
to  escape  him."    George  H.  Rohe.] 

One  of  the  most  persistent  delusions 
of  melancholia  is  that  there  is  destruc- 
tion of  the  abdominal  viscera  and  that  no 
food  can  pass;  that,  if  taken  it  will  not 
pass  and  that  it  will  cause  the  patient's 
death  if  forced  upon  him.  The  com- 
])lai7ils  of  being  "rotten  inside"  are  fre- 
quent among  melancholiacs.  The  phys- 
ical demonstration  of  eating  a  meal,  of 
living  through  it  and  maintaining  the 
strength,  and  of  the  regular  continuance 
of  defecation  has  no  effect  upon  the  de- 


lusion. It  persists  in  spite  of  the  con- 
stant contradictions  which  the  patient 
himself  furnishes.  On  the  other  hand, 
it  must  be  borne  in  mind  that  the  sensa- 
tions of  obstruction  may  be  real,  and 
that  an  actual  stenosis  of  the  bowel  may 
be  present.  Such  cases  have  been  re- 
ported by  Clouston  and  by  me. 

The  delusion  that  the  patient  has  com- 
mitted "the  unpardonable  sin"  or  "the 
sin  against  the  Holy  Ghost"  is  an  ex- 
tremely obstinate  one.  Savage  regards 
this  delusion  as  an  unfavorable  one,  as 
patients  manifesting  it — "the  unpardon- 
able sinners,"  as  he  calls  them — rarely 
recover.  The  nature  of  the  unpardonable 
sin  varies  with  different  persons.  Most 
of  them  cannot  or  will  not  define  it. 

In  some  cases  the  fear  of  impending 
death  colors  all  thoughts  and  actions  of 
the  patient.  Food  and  medicine  are  re- 
fused, because  the  patient  will  presently 
die.  Xothing  can  be  done  to  prevent  it. 
In  other  cases  all  friends  have  deserted 
the  patient,  and  there  is  nothing  left  but 
to  die. 

Most  melancholiacs  are  more  or  less 
passive  and  quiet;  beyond  making  ver- 
bal complaints  of  their  sufferings  they 
sit  and  brood  over  their  troubles,  which 
are  always  real  to  them.  In  other  cases, 
however,  there  is  great  restlessness.  The 
patients  are  constantly  in  motion,  crying 
and  lamenting,  sometimes  under  the 
stress  of  their  delusions  there  are  out- 
breaks of  violence,  although  these  are 
rare. 

The  suicidal  tendency  is  present  in  a 
large  proportion  of  melancholiacs.  Life 
is  usually  taken  by  violent  means.  Hang- 
ing, shooting,  jumping  from  a  height, 
cutting  the  throat,  and  drowning,  are  the 
most  frequent  methods.  Even  such  pain- 
ful methods  as  burning,  and  swallowing 
broken  glass  are  resorted  to.  The  at- 
tempts are  sometimes  very  persistent. 


INSANITY. 


MELANCHOLIA. 


SYMPTOMS. 


79 


Sometimes  melancholia  is  combined 
with  a  stuporose  condition, — "melan- 
cholia with  stupor."  In  these  cases  the 
patient  sits  or  stands  all  day  long,  mute, 
apparently  taking  no  note  of  anything 
going  on  around  him.  There  is  some- 
times also  resistance  to  everything  done 
for  the  patient.  Some  authors  class  the 
affection  described  by  Kahlbaum  under 
the  name  catatonia  with  stuporose  melan- 
cholia, but  in  my  opinion,  catatonia  be- 
longs to  the  group  of  which  general 
paresis  is  the  type. 

Causation". — i^nything  that  depresses 
the  general  nutrition  in  one  predisposed 
to  insanity  may  cause  melancholia.  The 
essential  physical  substratum  of  the  dis- 
ease is  probably  cerebral  anaemia,  al- 
though at  present  the  morbid  anatomical 
condition  of  the  brain  in  melancholia  is 
not  known. 

Melancholia  believed  to  be  a  symptom 
of  trophic  disturbances  of  the  anterior 
brain  and  the  opposite  to  mania.  In 
the  latter  there  is  an  exalted  disposition 
and  increase  of  the  cortical  functions  of 
movement  and  megalomania.  In  the  for- 
mer there  is  a  sad  disposition,  a  de- 
crease of  movement,  and  micromania,  the 
delirium  of  which  is  of  self-reproach. 
The  basis  of  this  depressed  disposition 
lies  in  the  want  of  functional  hyperemia 
of  the  cortex,  which  latter  state,  if  exag- 
gerated, produces  the  exalted  disposition 
of  mania.  Meynert  (Wiener  med.  Presse, 
June  6,  '89). 

Although  melancholia  may  not  be 
caused  by  an  impoverishment  of  the 
blood  per  se,  such  impoverishment  almost 
invariably  exists,  and,  in  a  large  ma- 
jority of  cases,  improvement  of  the 
mental  symptoms  is  coincident  with  im- 
provement in  the  general  health  and  in 
the  quality  of  the  blood.  Whitmore 
Steele  (Amer.  Jour,  of  Insanity,  Apr., 
'93). 

Three  cases  of  well-marked  melan- 
cholia apparently  dependent  upon  local 
pelvic  disease.  These  cases  recovered, 
physically  and  mentally,  after  appropri- 


ate local  treatment.  One  of  the  cases 
had  been  insane  four  years,  and  had  been 
nine  months  in  an  insane  hospital.  W. 
Gill  Wylie  (Med.  Rec,  Aug.  4,  '94). 

Analysis  of  730  consecutive  cases  of 
melancholia  admitted  to  the  Carlisle 
Asylum  during  twenty-seven  years. 
Taking  the  three  grand  groups  of  mental 
diseases, — melancholia,  mania,  and  de- 
mentia,— melancholia  formed  a  fraction 
over  25  per  cent., — 334  males  and  396 
females;  58  per  cent,  were  discharged 
recovered,  8  per  cent,  relieved,  4  per  cent, 
unimproved,  and  20  per  cent,  died;  219 
were  cases  of  simple  melancholia  and  511 
melancholia  with,  delusions;  65  per  cent, 
had  suicidal  tendencies,  self-destruction 
being  actually  attempted  in  33  per  cent.; 
in  29  per  cent,  some  physical  disease  co- 
existed with  the  mental  disorder.  The 
physical  diseases  most  frequently  present 
were  phthisis  (70  cases),  heart  disease 
(57  cases),  and  cancer  (10  cases).  Two- 
thirds  of  the  cases  were  between  30  and 
60  years  of  age.  The  largest  proportion 
of  recoveries  occurred  between  10  and  30 
years.  The  proportion  of  relapses  was  22 
per  cent.  Hereditary  predisposition  was 
ascertained  in  38  per  cent. 

Leaving  out  of  consideration  heredi- 
tary predisposition  and  previous  attacks, 
the  cause  of  melancholia  was  found,  in 
a  marked  preponderance  of  cases,  to  be 
of  a  physical  nature.  In  over  400  of  the 
730  cases  there  was  ascertained  to  be 
some  such  cause  at  work  in  originating 
the  mental  depression.  Intemperance  in 
drink  was  assigned  as  a  cause  in  84 
cases,  pregnancy  in  7,  parturition  and 
the  puerperal  state  in  20,  lactation  in 
23,  privation  and  starvation  in  28,  and 
in  a  large  number  of  other  cases  there 
was  some  kind  of  physical  disorder  pre- 
ceding the  melancholia.  In  about  250 
cases  the  mental  depression  was  assigned 
to  some  moral  cause.  W.  F.  Farquharson 
(Jour,  of  Mental  Sci..  Jan.,  Apr.,  '94). 

Literature  of  '96-'97-'98. 

Case  of  melancholia  in  which  the  pa- 
tient had  for  two  years  suffered  from 
hallucinations  of  hearing.  He  became 
depressed,  sleepless,  ana  took  to  drink. 
The  voices  heard  were  those  of  friends 
far  away,  and  they  goaded  him  on  to 


80 


INSANITY.    MELANCHOLIA.  DIAGNOSIS. 


destroy  himself  in  order  to  avoid  dis- 
grace. 

He  had  constant  headache  on  the  left 
side,  and  had  attempted  to  cut  his 
throat. 

Trephined,  making  a  large  opening 
over  the  centre  for  hearing,  and  found 
a  serous  cyst,  which  was  drained.  The 
patient  completely  recovered.  Street 
and  Damer  Harrison  (Liverpool  Medico- 
Chirurgical  Jour.,  July,  '97). 

In  about  one-half  of  all  cases  there  is 
a  psychopathic  ancestry. 

Diagnosis. — In  many  forms  of  insanity 
psychical  depression  is  a  stage  in  the  de- 
velopment of  the  disorder.  Thus,  mania 
mostly  begins  with  depression;  in  general 
paresis,  although  the  feelings  are  usually 
exalted,  there  may  be  a  depressive  stage 
lasting  nearly  throughout  the  disease. 
Many  cases  of  paranoia  have  a  melan- 
choly tinge,  and  in  the  toxic  psychoses 
depression  is  not  an  unusual  symptom. 
True  melancholia  must,  however,  be  dif- 
ferentiated from  these  episodic  depres- 
sions. 

In  true  melancholia  every  emotion, 
thought,  and  act  is  dominated  by  the 
sense  of  profound  depression.  Nothing 
can  dissipate  the  cloud  of  sadness  that 
envelopes  the  patient.  He  is  lost;  there 
is  neither  relief  for  him  in  this  world  nor 
salvation  in  the  next. 

Literature  of  '96-'97-'98. 

The  diagnostic  criteria  of  incipient  or 
simple  melancholia  may  be  reduced  to 
the  following  clinical  symptoms:  — 

1.  Mental  depression  presenting  all 
degrees  of  depressed  states  of  feeling. 

2.  Insomnia,  which  may  be  slight  or 
profound,  but  usually  very  persistent. 

3.  Headache  or  psychalgia,  which  is 
commonly  referred  to  the  occipital 
region. 

4.  Loss  of  normal  body-weight,  pre- 
senting all  degrees. 

5.  Changes  in  attitude  and  physiog- 
nomy. 

6.  Impaired  appetite  with  marked  con- 
stipation. 


7.  Morbid  introspection  with  selfish  in- 
clinations. 

8.  Morbid  fear  of  objects  or  places 
constituting  the  phobias. 

When  these  symptoms  present  them- 
selves in  any  individual  and  become  per- 
sistent, whether  the  cause  be  known  or 
not,  they  constitute  the  actual  presence 
of  that  form  of  incipient  insanity  known 
as  simple  melancholia.  John  Punton 
(Alienist  and  Neurologist,  Oct.,  '98). 

In  catatonia  there  is  rhythmical  forms 
of  movement  and  of  speech  alternate 
with  rigidity  and  mutism.  The  rigidity 
affects  mostly  the  muscles  of  the  neck 
and  shoulders.  Attention  drawn  to  the 
fact  that  rigidity  of  this  nature  is  not 
confined  to  cases  of  catatonia.  It  also 
exists  in  all  cases  of  melancholia  to  a 
greater  or  less  degree;  but  it  is  espe- 
cially marked  in  severe  cases  of  the  dis- 
ease, and  especially  in  those  cases  in 
which  there  is  an  element  of  stupor. 
It  is  most  marked  in  the  muscles  of  the 
trunk  and  neck;  it  is  less  marked,  but 
very  strikingly  present,  in  the  muscles 
Of  the  shoulders  and  hips,  and  it  is  again 
less  marked  in  the  elbows  than  at  the 
shoulders,  less  marked  at  the  wrists  than 
at  the  elbows,  and  it  is  practically  ab- 
sent from  the  fingers.  Similarly  the 
rigidity  is  less  marked  at  the  knees  than 
at  the  hips,  very  slight  at  the  ankles, 
and  again  practically  absent  from  the 
toes. 

Personal  reasons  for  believing  this 
proximal  rigidity  to  be  a  true  physical 
sign  of  melancholia  are:  — 

1.  That  it  does  not  occur  in  other 
forms  of  insanity. 

2.  That  it  disappears  from  the  patient 
as  he  gets  well. 

3.  That  voluntary  rigidity  is  of  the 
peripheral  type. 

This  is  best  observed  in  a  resistant 
child. 

Since  rigidity  is  frequently  associated 
with  paralysis,  one  naturally  endeavored 
to  ascertain  whether  there  was  any 
weakness  of  movement  at  those  joints 
where  the  rigidity  was  most  marked. 
This  paralysis  has  been  detected.  There 
is  very  little  weakness  to  be  detected  in 
the  elbow-  or  wrist-  movements,  but.  if 
such   a   patient   be  asked  to  hold  his 


INSANITY. 


MELANCHOLIA. 


TREATMENT. 


81 


hands  straight  above  his  head,  he  has 
difficulty  in  doing  so;  and  it  will  be 
observed  in  extreme  cases  that  the  upper 
arm  is  not  nearly  held  vertically,  and 
that  the  elbow  is  not  quite  fully  ex- 
tended. 

This  symptom  seems  most  marked  in 
those  patients  who  suffer  a  large  amount 
of  mental  pain,  especially  if  associated 
with  an  element  of  stupor. 

The  conclusion  is  that  in  cases  of 
melancholia  the  cells  of  the  tissues 
throughout  the  body  have  their  function 
of  excretion  diminished,  as  well  as  the 
cells  of  the  cortex  cerebri.  W.  H.  B. 
Stoddart  (Journal  of  Mental  Science, 
Apr.,  '98). 

Prognosis. — This  is  generally  favor- 
able. Under  appropriate  treatment, 
from  75  to  80  per  cent,  of  cases  should 
recover. 

While  melancholia  in  its  uncompli- 
cated stage  is  the  most  common  of  all 
forms  of  insanity,  it  nevertheless  is  per- 
haps the  most  curable.  John  Punton 
(Alienist  and  Neurologist,  Oct.,  '98). 

Treatment. — One  of  the  first  questions 
usually  asked  the  physician  who  is  con- 
sulted in  a  case  of  mental  disturbance  is: 
can  the  patient  be  treated  at  home,  or  is 
removal  to  an  institution  necessary?  In 
cases  of  melancholia  home  treatment  is 
often  practicable,  if  an  attendant  with 
tact  and  firmness  is  secured.  Even 
under  these  favorable  circumstances, 
however,  treatment  in  an  institution 
should  be  advised.'  Eefusal  of  food  and 
medicine  must  be  met  with  positiveness, 
and  in  case  of  resistance  forcible  feeding 
must  be  practiced.  It  is  rarely  necessary 
to  resort  to  the  nasal  or  oesophageal  tube, 
and,  in  those  cases  in  which  it  must  be 
employed,  a  few  trials  are  usually  suffi- 
cient and  the  patient  will  thereafter  take 
his  meals  with  a  little  coaxing.  It  is  not 
sufficient  to  know  that  the  patient  eats; 
the  physician  must  assure  himself  that 
the  quantity  of  food  is  sufficient  to  main- 
tain the  standard  of  normal  nutrition. 


As  refusal  of  food  is  sometimes  due  to 
gastric  or  intestinal  disorders,  the  patient 
should  always  be  carefully  examined  to 
determine  whether  the  gastro-intestinal 
canal  is  in  normal  condition.  Catarrhal 
conditions  demand  appropriate  treat- 
ment, and  want  of  digestive  power  may, 
at  times,  be  relieved  by  tonics,  stimulants, 
and  digestives.  For  brief  periods,  con- 
centrated or  partially  digested  foods, 
such  as  beef-juice,  clam-juice,  peptones, 
etc.,  may  be  employed  with  benefit. 

For  cases  in  which  there  is  insufficient 
nutrition,  but  which  will  take  food,  dry 
peptones  dissolved  in  Malaga  wine  recom- 
mended, and  especially  the  following 
composition:  Raw,  chopped  meat,  3 
ounces  2  drachms;  powdered  sugar,  1 
ounce  2  drachms;  Malaga  wine,  1  ounce 
2  drachms ;  tincture  of  cinnamon,  1 1/i 
drachms.  To  avoid  the  danger  of  tseniae, 
mutton  is  used  or  the  chopped  meat  may 
be  brought  for  a  minute  to  a  high  tem- 
perature. For  feeding  by  a  tube  the 
following  daily  ration  is  recommended: 
Four  eggs,  2  quarts  of  milk,  8  ounces  of 
Bordeaux  wine,  1  ounce  of  meat-powder, 
with  an  addition  of  2 1/2  drachms  of 
common  salt.  Lailler  (Annales  Med.- 
psychol.,  Jan.,  '89). 

Nux  vomica  or  strychnine,  quinine, 
phosphorus,  or  codliver-oil  will  often  be 
found  of  use. 

The  systematic  use  of  stomach-wash- 
ing also  promises  good  results  in  these 
cases. 

There  is  usually  constipation  in  melan- 
cholia. This  should  be  counteracted  by 
the  nightly  administration  of  compound 
licorice  powder,  cascara  sagrada,  or  one 
of  the  usual  anticonstipation  pills.  A 
mercurial  followed  by  a  saline  purgative 
is  good  initiatory  treatment,  and  a  weekly 
repetition  of  the  mercurial  will  be  found 
beneficial. 

Perhaps  the  most  important  remedy 
in  acute  melancholia  is  rest  in  bed.  The 
depressed  state  of  nutrition  is  a  strong 
indication  for  bed-rest.    It  will  be  found 


4—6 


S2 


INSANITY.    MELANCHOLIA.  TREATMENT. 


that  the  patients  quickly  respond  to  the 
good  effects  of  this  treatment.  Super- 
vision of  suicidal  cases  is  also  much  easier 
if  patients  are  kept  in  bed. 

Literature  of  '96-'97-'98. 

Bed-treatment  strongly  advocated  in 
acute  psychoses,  especially  in  melan- 
cholia. Serieux  (Rev.  de  Psychiatriex 
No.  8,  '97). 

The  best  treatment  for  melancholia  is 
to  encourage  the  patient  to  sink  his  own 
personality,  in  trying  to  help  and  uplift 
those  who  are  in  need  around  him.  W. 
Xavier  Sudduth  (Med.  Times,  Jan.,  '98). 

The  production  of  sleep  is  most  im- 
portant. Depressing  hypnotics,  such  as 
chloral,  bromide  of  potassium,  etc.,  are 
not  beneficial.  If  an  hypnotic  is  neces- 
sary, morphine,  sulphonal,  or  paralde- 
hyde should  be  used. 

Sulphonal  is  an  hypnotic  of  most  re- 
markable intrinsic  value  in  cases  of  in- 
sanity in  doses  of  30  to  75  grains.  The 
use  of  sulphonal  is  sometimes  attended 
with  vertigo  and  difficulty  in  keeping 
the  equilibrium,  the  patient  appearing, 
in  this  respect,  as  if  intoxicated.  It  may 
possibly  be  contra-indicated  in  the  con- 
gestive forms  of  insanity.  Gamier  (Der 
Praktische  Aerzt,  Jan.,  Mar.,  '89). 

It  is  preferred  to  give  sulphonal  dry 
on  the  tongue,  to  be  followed  by  a  liquid. 
The  phosphates  in  the  urine  are  increased 
by  small  and  diminished  by  large  doses. 
The  action  on  the  heart  is  opposed  to 
that  of  digitalis.  John  Gumming  Mac- 
kensie  (New  England  Med.  Monthly, 
July,  '91). 

Trional  preferred  to  tetronal  or  sulpho- 
nal because  of  its  greater  efficacy  and 
the  absence  of  all  poisonous  symptoms 
from  its  use.  Having  a  bitter  taste,  it 
should  be  given  in  as  large  a  quantity 
of  some  warm  liquid  as  possible,  in 
doses  of  from  15  V2  to  46  grains.  Randa 
(Inter,  klin.  Rund.,  Mar.  5,  '93). 

As  trional  may  cause  unpleasant 
effects  in  patients  affected  with  heart 
disease,  especially  where  there  is  defect- 
ive compensation,  it  should  be  prescribed 


in  such  cases  with  the  greatest  caution. 
Keppers  (These  de  Wurzbourg,  '93). 

Chlorobrom  is  most  favorable  in  melan- 
cholia, especially  of  the  milder  type; 
and  in  acute  mania  its  action  is  fully  as 
reliable  and  lasting  as  any  other  hyp- 
notic we  possess.  Wade  (Amer.  Jour, 
of  Insan.,  Apr.,  '95). 

Chlorobrom  highly  recommended  in 
melancholia  and  brain-exhaustion  from 
overwork,  when  insomnia  is  the  most 
serious  symptom  to  combat.  Keay  (Lan- 
cet, Mar.  18,  '95). 

In  15  cases  of  melancholia  the  galvanic 
current  produced  remarkably  good  re- 
sults. Jules  Morel  (Bull,  de  la  Soc.  de 
Med.  Mentale  de  Belgique,  Mar.,  '89). 

A  pint  of  ale  or  beer,  or  a  glass  of 
whisky  and  water  is  often  a  better  hyp- 
notic than  the  medicines  mentioned. 

The  tendency  to  suicide  in  melan- 
cholia requires  careful  and  constant 
watchfulness.  The  patients  with  suicidal 
tendencies  often  display  great  shrewd- 
ness in  lulling  the  suspicions  of  those 
having  them  in  charge.  The  most  at- 
tentive and  watchful  nurses  are  liable  to 
relax  their  care,  and,  before  preventive 
measures  can  be  adopted,  the  patient  has 
secured  a  weapon  and  taken  his  life.  The 
attendant  upon  a  melancholiac  must  have 
an  intelligent  appreciation  of  the  pa- 
tient's condition  and  of  the  persistence 
of  suicidal  impulses. 

Literature  of  '96-'97-'98. 

A  patient  with  melancholia,  especially 
the  agitated  and  the  stuporous  forms, 
should  never  be  left  alone  night  or  day. 
The  danger  of  suicide  is  always  present 
and  is  often  a  matter  of  sudden  impulse, 
peculiarly  liable  to  develop  if  the  patient 
is  alone.  The  diet  should  be  nutritious 
and  quite  sufficient.  A  low  diet,  so- 
called,  is  rarely,  if  ever,  indicated. 
Pritchard  (N.  Y.  Polyclinic,  Mar..  »96). 

The  medicinal  agent  of  most  value  is 
opium.  Many  alienists  object  to  its  use 
on  account  of  the  alleged  danger  of  con- 
tracting the  opium  habit,  but  when  the 


INSANITY. 


MELANCHOLIA. 


TREATMENT. 


83 


drug  is  disguised  and  is  systematically 
administered,  this  danger  can  be  guarded 
against.  It  is  best  given  in  the  form  of 
deodorized  tincture  diluted  with  whisky 
and  combined  with  a  laxative,  as  cascara, 
to  diminish  the  constipating  effects  of 
the  remedy.  The  latter,  however,  are  not 
very  marked  after  the  medicine  has  been 
taken  a  few  days.  The  beginning  dose 
is  5  minims  of  the  deodorized  tincture, 
gradually  increased  to  30  or  even  40 
minims  twice  a  day.  Stress  is  laid  on 
the  regular  administration  of  the  drug. 
When  opium  or  morphine  are  given  at 
regular  times  to  reduce  anxiety  or  pro- 
duce sleep,  it  fails  entirely  in  producing 
its  beneficial  curative  effect  in  melan- 
cholia. When  the  desired  effects  (quiet, 
diminution  of  intensity  of  hallucinations 
and  delusions,  disappearance  of  mental 
depression)  have  been  obtained,  the  dose 
is  gradually  reduced  to  the  vanishing- 
point.  . 

In  some  cases  the  opium  produces  so 
much  gastric  irritability  that  it  must  be 
suspended.  These  are,  however,  very 
few. 

Results  of  personal  observations  upon 
the  use  of  opium  in  the  treatment  of 
melancholia  summarized  as  follows:  1. 
Rest  in  bed  for  a  prolonged  period.  2. 
Every  morning  the  patient  is  given  on 
waking  a  glass  of  Hunyadi  water,  pre- 
venting in  this  way  the  disturbing  effects 
of  constipation.  3.  Tincture  of  nux 
vomica  is  given  in  small  doses  twice 
daily  before  the  two  principal  meals  of 
the  day.  4.  Laudanum  is  used  in  pro- 
gressive doses,  commencing  with  5  drops 
and  increasing  5  drops  each  day  until 
distinct  improvement  in  the  patient's 
condition  is  observed.  The  writers  have 
never  had  occasion  to  exceed  200  drops 
daily. 

After  there  has  been  a  marked  im- 
provement observed  in  the  physical  con- 
dition  spray-baths  of  short  duration  are 
employed.  Bell  and  Lemoine  (Annales 
Medico-ppychol.,  Jan.,  Mar.,  '89.) 


Systematic  observation  extending  over 
two  years,  and  embracing  the  employ- 
ment of  over  18,000  single  aoses  of  opium 
in  the  treatment  of  various  forms  of 
mental  disturbance.  The  treatment  em- 
braced over  40  cases  of  melancholia,  4 
of  typical  mania,  and  50  of  various  forms 
of  paranoia.  Of  the  43  patients  of  melan- 
cholia, 2  died  of  intercurrent  diseases,  2 
were  removed  by  relatives,  and  31  re- 
covered. Although  this  success  certainly 
cannot  be  wholly  due  to  opium,  as  good 
food,  rest  in  bed,  etc.,  had  a  great  share 
in  producing  the  favorable  results,  still 
the  beneficial  effects  of  the  opium  cannot 
be  denied.  In  those  cases  which  did  not 
improve  under  the  use  of  opium,  6  were 
afflicted  with  a  marked  delusional  state, 
with  excessive  mental  disturbance.  The 
opium  was  wholly  given  by  the  mouth, 
and  the  constipation,  which  was  observed 
in  about  50  per  cent,  of  the  cases,  was 
successfully  relieved  by  the  fluid  extract 
of  cascara  sagrada,  and  the  diarrhoea, 
which  was  observed  at  the  height  of  the 
treatment  and  at  the  suspension  of  the 
opium,  by  tincture  of  koto,  10  to  20 
drops.  It  would  be  perfectly  justifiable 
to  continue  the  use  of  the  opium  for  at 
least  a  year,  if  it  could  be  shown  that 
the  intellect  was  not  being  impaired  by 
its  employment.  In  mania  the  bromides 
and  hyoscine  can  be  used  to  better  ad- 
vantage. Theodore  Ziehen  (Therap. 
Monats.,  Feb.,  Mar.,  '89). 

Literature  of  '96-'97-'98. 

In  considering  the  usefulness  of  any 
particular  line  of  treatment  in  melan- 
cholia, due  weight  must  be  given  to  the 
tendency  of  this  disease  to  recovery  in 
the  great  majority  of  cases. 

Taking  then  the  indication  suggested 
by  the  age  of  the  patient  for  or  against 
the  use  of  opium,  patients  of  fifty  years 
of  age  and  over  react  most  strikingly 
to  its  employment,  and  rapidly  improve 
under  its  use.  On  the  other  hand,  pa- 
tients of  about  thirty  years  of  age  and 
under  are  made  notably  worse  by  it. 
Those  between  the  ages  of  fifty  and 
thirty  react  uncertainly  to  opium;  and 
where  such  cases  <1<>  improve  the  progress 
toward  recovery  is  much  slower  than  in 
older  patients.    It  does  not  appear  that 


84 


INSANITY.    MANIA.  SYMPTOMS. 


the  form  in  which  opium  is  given  is  of 
much  importance. 

The  dose  should  always  be  rapidly 
pushed  to  the  limits  of  tolerance;  and 
also  continued  sufficiently  long  to  give 
it  a  fair  trial. 

In  looking  for  a  substitute  for  opium 
in  cases  of  melancholia  in  the  first  half 
of  life,  no  drug  has  given  such  good  re- 
sults as  sulphonal.  Given  in  average 
doses  of  30  grains  each  night  it  speedily 
acts  not  only  by  inducing  sound  and 
refreshing  sleep,  but  also  by  what  might 
be  called  its  after-effects:  it  makes  a 
patient  rather  heavy  during  the  day  fol- 
lowing its  administration.  This  is  an 
advantage ;  there  seems  to  be  mental  suf- 
fering, and  suicidal  tendencies  and  ob- 
stinate refusal  of  food  are  often  relieved. 
This  after-effect  of  sulphonal  must  be 
reached  by  increasing  the  dose  with 
caution  if  necessary,  and  maintaining  it 
for  a  few  days  in  the  full  amount,  then 
gradually  reducing  it,  and  only  increas- 
ing again  if  there  is  any  threatening  of 
a  relapse. 

It  has  not  been  found  necessary  to  give 
a  larger  quantity  than  30  grains;  they 
always  begin  with  this  dose,  and  never 
give  it  more  frequently  than  every  night. 
J.  R  Gasquet  and  J.  A.  Cones  (Journal 
of  Mental  Science,  July,  '97). 

An  important  thing  in  all  cases  of 
melancholia,  as  in  other  forms  of  insan- 
ity, is  a  careful  examination  of  all  the 
bodily  organs,  and  the  treatment  of  such 
as  are  diseased. 

Mania. 

Definition. — An  abnormal  exaltation 
of  mental  activity,  with  incoherence,  hal- 
lucinations, illusions,  and  delusions  of 
variable  character.  There  is  reason  to 
believe  that  mania  is  accompanied  by  an 
hyperemia  of  the  cerebral  cortex. 

These  symptoms  may  all  occur  as  a 
stage  in  some  other  form  of  mental  dis- 
turbance. Thus,  paranoia,  general  pa- 
resis, gross  brain  disease,  and  develop- 
mental psychoses  may  have  maniacal  at- 
tacks as  part  of  the  clinical  history.  In 


true,  uncomplicated  mania  the  exalta- 
tion is  the  characteristic  manifestation. 

Symptoms  and  Course. — An  outbreak 
of  mania  is  usually  preceded  by  some 
days  or  weeks  of  depression  or  irritability 
of  the  patient.  He  loses  appetite,  the 
sleep  becomes  disturbed,  and  there  is  ob- 
served a  disinclination  to  his  usual  occu- 
pation. Sometimes  there  is  headache,  or 
a  sense  of  pressure  in  the  head.  These 
symptoms,  after  a  time,  become  changed 
in  character.  The  depression  disappears, 
the  patient  feels  exalted  and  becomes 
talkative.  If  asked  about  his  health,  he 
will  tell  you  he  is  well — "never  felt  bet- 
ter in  his  life,"  etc.  Schemes  for  his  own 
advancement  or  that  of  others  are  re- 
garded in  an  optimistic  spirit.  Visits  are 
made  to  friends  and  acquaintances  and 
private  business  affairs  are  discussed  with 
more  prolixity  and  less  reserve  than  are 
usually  agreeable  to  others  concerned. 
The  recollection  of  past  events  is  some- 
times very  accurate  and  the  minutest  and 
least  important  details  of  some  long  past 
transaction  are  often  recounted  in  the 
most  wearying  manner  for  the  hearer. 
The  patient  in  this  stage  does  not  care 
whether  you  reply  to  him  or  not.  He 
only  wants  a  good  listener  into  whose 
ears  he  can  pour  his  connected  or  dis- 
jointed verbosity.  He  also  usually  be- 
comes a  voluminous  letter-writer.  In 
some  cases  there  is  a  tendency  to  make 
rhymes  which  are  sometimes  very  in- 
genious. This  must  be  differentiated 
from  the  verbigeration  or  chattering  of 
delirium  or  of  acute  confusional  insanity. 

The  persistence  of  hallucinations  and 
delusions  in  melancholia  and  paranoia  is 
usually  absent  in  mania.  In  this  form  of 
mental  disturbance  there  is  usually  rapid 
change  of  delusions  and  hallucinations, 
often  without  apparent  cause.  The  false 
sense-perceptions  and  ideas  vary  as 
rapidly  as  they  sometimes  do  in  dreams. 


INSANITY.    MANIA.    SYMPTOMS.  DIAGNOSIS. 


85 


If  unopposed  in  his  irrational  notions, 
the  patient  is  usually  in  a  cheerful,  even 
happy  frame  of  mind.  Contradiction  or 
opposition  soon  lead  to  irritability,  and 
at  times  the  patient  may  become  so 
angry  as  to  be  uncontrollable.  Under 
these  circumstances  maniacs  may  commit 
acts  of  violence,  the  patient's  anger  be- 
ing entirely  beyond  his  control.  On  the 
other  hand,  if  the  delusions  are  encour- 
aged they  "increase  by  what  they  feed 
on"  and  grow  more  persistent  and  in- 
sistent. 

In  connection  with  the  mental  exalta- 
tion there  is  often  great  restlessness. 
The  patient  may  continue  doing  his  usual 
work,  but  he  does  everything  in  a  hurry. 
There  is  a  more  lively  play  of  the  facial 
expression.  The  patient  frequently 
poses  for  effect.  This  is  perhaps  equally 
frequent  in  the  two  sexes,  although  more 
marked  in  women.  Sexual  desire  is  also 
enhanced,  and,  in  advanced  stages  women 
are  likely  to  exceed  males  in  obscenity  of 
speech  and  action.  Masturbation  is 
sometimes  observed  in  mania,  but  much 
less  frequently  than  in  epileptic  insanity. 
The  open  practice  of  the  vice  is  compara- 
tively rare. 

In  the  more  severe  forms  of  mania  all 
these  manifestations  are  intensified.  The 
rapid  movements,  the  shouting  and 
laughing,  incoherence,  obscenity,  and 
profanity  are  greatly  heightened  in  de- 
gree. 

Articles  of  clothing,  bedding,  furni- 
ture, in  short,  anything  that  offers  oppor- 
tunity for  tearing  or  breaking  are  liable 
to  suffer  destruction  at  the  hands  of  the 
maniacal  patient.  He  loses  control  over 
his  sphincters,  and  wets  and  soils  his  bed 
and  clothing,  or  defecates  on  the  floor 
and  then  dabs  his  body  or  the  walls  of 
his  room  with  his  excreta.  There  seems 
to  be  anaesthesia  in  some  cases;  at  all 
events  slight  injuries,  that  in  the  normal 


condition  would  give  rise  to  complaints 
of  pain,  are  either  not  felt  or  are  thought 
unworthy  of  notice. 

Fever  is  present  in  a  considerable  pro- 
portion of  cases  of  acute  mania.  It 
should  always  lead  to  a  careful  physical 
examination  to  determine  the  presence 
of  any  local  inflammatory  condition.  In 
two  recent  cases  under  notice  the  fever 
was  due  to  considerable  collections  of 
pus.  In  one  of  these  no  pain  was  com- 
plained of;  and  yet  on  examination  a 
large  perirectal  abscess  was  discovered 
which  discharged  about  ten  ounces  of 
pus  when  opened.  Mere  functional  de- 
rangement of  the  mind  is  not  likely  to 
cause  appreciable  elevation  of  tempera- 
ture. There  can  nearly  always  be  found 
some  direct  cause  for  the  fever,  either 
inflammatory  or  septic.  The  inflamma- 
tion may  be  in  the  brain  or  its  mem- 
branes, in  the  abdominal  viscera,  the 
pelvis,  the  external  ear,  the  integu- 
mentary tisues,  or  the  peripheral  nerv- 
ous system  (neuritis).  The  septic  infec- 
tion may  start  from  a  wound,  an  abscess, 
or  a  diphtheritic  patch,  or  it  may  be  in 
the  blood  itself,  as  in  various  specific 
febrile  conditions.  Even  when  no  phys- 
ical cause  can  be  discovered,  fever  is  al- 
ways a  grave  symptom,  since,  if  it  rises 
too  high,  exhaustion  supervenes  more 
rapidly. 

The  pulse  in  mania  is  usually  full  and 
regular.  But  when  there  is  beginning 
exhaustion,  as  in  those  cases  where  the 
patient  is  constantly  moving  about,  with 
insufficient  food  and  sleep,  the  pulse  is 
small  and  rapid.  In  these  cases  death 
from  exhaustion  is  not  infrequent. 

An  attack  of  mania  may  terminate  in 
one  of  four  different  ways:  (1)  recovery; 
(2)  death  from  exhaustion;  (3)  chronic 
mania;  (4)  consecutive  dementia. 

Diagnosis. — The  diagnosis  of  the  clin- 
ical form  of  mental  disturbance  termed 


INSANITY.    MANIA.    DIAGNOSIS.  CAUSATION. 


86 

mania  is  sometimes  rather  difficult.  As 
before  stated,  many  forms  of  insanity 
have  a  maniacal  stadium  which  may  be, 
and  often  is,  mistaken  for  a  special  dis- 
ease. Hence  prolonged  observation,  ex- 
tended over  days  and  sometimes  weeks, 
is,  at  times,  necessary  to  form  a  positive 
judgment.  The  greatest  difficulty  occurs 
in  those  cases  due  to  septic  or  toxic  causes 
which  by  many  are  not  differentiated 
from  true  mania.  In  these  cases  the 
exaltation  is  often  only  apparent,  the 
essential  and  characteristic  manifesta- 
tions being  mental  confusion  or  delirium. 

The  terms  "acute  confusional  insan- 
ity," "acute  delirious  mania/'  etc.,  show 
that  observers  generally  recognize  a  dif- 
ference between  these  cases  and  those  of 
simple  mania.  In  the  latter  the  essen- 
tial manifestations  are  the  exaltation, 
flight  of  ideas,  and  rapidly  changing 
hallucinations  and  delusions. 

Three  conditions  present  separate  hys- 
terical mania  from  simple  acute  mania, 
or  mania  with  delusions.  They  are: 
retention  of  memory,  absence  of  mental 
perversion,  and  purposive  conduct. 
Tomlinson  (Jour,  of  Nerv.  and  Mental 
Dis.,  Apr.,  '91). 

Literature  of  '96-'97-'98. 

Acute  delirium  and  acute  mania  are 
frequently  mistaken  for  each  other,  and 
their  diagnosis  from  each  other  is  some- 
what difficult  to  make.  The  tempera- 
ture is  elevated  in  acute  delirium,  and 
lowered  in  mania.  The  exhaustion  is 
very  rapid  in  acute  delirium,  while  the 
maniac  will  continue  to  rave  for  months 
with  little  perceptible  loss  of  strength. 
Mania  is  a  conscious  delirium,  the  pa- 
tient being  aware  of  what  he  is  doing 
and  taking  every  advantage  of  others; 
acute  delirium  is  an  unconscious  de- 
lirium, the  patient  never  Irving  to  take 
any  advantage,  and,  although  lie  recog- 
nizes people,  five  minutes  later  he  does 
not  remember  to  have  spoken  to  them. 
In  mania  the  appetite  is  often  enormous; 
in  acute  delirium  it  is  always  absent. 


Mania  is  preceded  by  marked  pro- 
dromata;  the  prodromata  of  acute  de- 
lirium are  never  very  marked  and  are 
often  absent.  In  mania  the  face  is  often 
flushed  and  the  sclerotic  injected;  in 
acute  delirium  the  face  is  pallid  and 
there  is  no  injection  of  the  sclerotic. 
Acute  delirium  will  terminate  in  death 
or  recovery  in  two  or  three  weeks;  mania 
will  require  months.  Coston  (Nashville 
Jour.  Med.  and  Surg.,  Aug.,  '96). 

Causation. — Aside  from  the  influence 
of  heredity,  which  can  be  traced  in  one- 
half  or  more  of  the  cases,  prolonged  ex- 
citement of  the  cerebral  centres,  over- 
work, and  mental  strain  of  various  kinds 
may  be  regarded  as  etiological  factors. 

All  manias  of  an  acute  type  which  are 
not  intoxication-neuroses,  and  are  not 
due  to  the  presence  of  organisms  in  the 
blood,  are  divisible  into  mania  proper 
and  confusional  insanity.  H.  C.  Wood 
(Amer.  Jour.  Med.  Sci.,  Apr.,  '95). 

The  infectious  origin  of  acute  delirium 
shown  in  eight  cases,  in  seven  cases  of 
which  recovery  or  considerable  improve- 
ment took  place,  eighth  ending  fatally. 
In  the  latter  only  did  the  blood  reveal 
presence  of  bacilli.  Bianchi  and  Piccino 
(Jour,  of  Nerv.  and  Mental  Dis.,  Aug., 
'95). 

Certain  forms  of  acute  mania  and  mel- 
ancholia are  due  to  nutritive  derange- 
ments. Lavage  of  the  stomach  and 
intestinal  disinfection  have  given  good 
results  in  these  cases.  E.  Toulouse 
(Jour,  de  MeU,  June  5,  '92). 

Literature  of  'dG-W-9&. 

Intestinal  putrescence  determines  the 
presence  in  the  urine  of  an  appreciable 
quantity  of  indican,  and  when  indican  is 
present  there  is  also  a  more  or  less 
marked  alteration  in  the  ratio  of  pre- 
formed sulphates.  These  indications  are 
generally  found  in  acute  insanities,  espe- 
cially those  characterized  by  rapidly 
developing  symptoms.  Changing  illu- 
sions, hallucinations  of  unsystematized 
delusions,  in  association  with  insomnia, 
pallor,  constipation,  and  rapid  exhaus- 
tion, are,  generally  due  to  autotoxis  of 
alimentary  origin,  and  this  condition  is 


INSANITY.    MANIA.    CAUSATION.  PROGNOSIS. 


87 


also  responsible  for  various  post-febrile, 
traumatic,  alcoholic,  and  drug  insanities. 
A.  McL.  Hamilton  (Med.  Press  and  Cir- 
cular, May  27,  '96). 

Masturbation  can  be,  and  often  is,  the 
sole  exciting  cause  of  insanity.  Ralph  A. 
Goodner  (Med.  News,  Feb.  27,  '97). 

Twenty  of  the  47  juvenile  cases  per- 
sonally observed  were  boys  and  14  girls; 
the  sex  of  the  others  was  not  stated. 
Of  the  13  cases,  8  were  boys  and  5  girls. 
Up  to  7  years  of  age  convulsions  and 
arrest  of  intelligence  are  most  commonly 
observed,  although  delirium  is  often  seen 
as  the  result  of  febrile  affections.  From 
7  to  14  years  of  age  true  mania  and 
melancholia  are  most  frequent,  while 
hysteria  shows  itself  very  often  as  soon 
as  the  menses  appear. 

Among  the  psychical  diseases  met  with 
dementia  is  frequently  observed.  Acute 
dementia,  which  is  the  most  common 
form,  frequently  occurs  betwen  the  ages 
of  10  and  16,  and  differs  from  senile  de- 
mentia "in  that  it  seems  to  depend  on 
the  imperfect  nutrition  of  the  nervous 
system,  and  is  generally  curable  by  gen- 
erous diet  and  other  means  that  supply 
materials  for  construction." 

Juvenile  dementia,  as  a  result  of  in- 
herited syphilis,  is  occasionally  met  with. 
Mental  deficiency  is  noticed  at  the  age 
of  the  second  dentition,  and  from  this 
time  gradual  degeneration  ensues,  with 
sometimes  paralytic  and  epileptic  seiz- 
ures, and  death  occurs  in  three  or  four 
years. 

Monomania,  or  delusional  insanity,  is 
commonly  met  with.  Erotomania  has 
been  observed  in  early  life.  The  expres- 
sion of  the  face  and  the  gestures  have 
an  amorous  languor,  but,  as  a  rule,  the 
children  so  affected  are  chaste.  Far 
more  important  is  nymphomania  and 
satyriasis,  due  no  doubt  to  the  influence 
of  heredity  and  exaltation  of  the  general 
sensibility. 

Melancholia  in  early  life  may  be  sud- 
den or  insidious  in  its  attack,  a  primary 
disorder,  or  the  sequel  of  some  other 
form  of  insanity.  There  are  two  forms: 
the  first,  a  pure  abstract  indefinable  de- 
pression; the  second,  a  despondent  con- 
dition, having  relation  to  religious  mat- 
ters or  a  future  state. 


In  mania  delusions  are  more  frequent 
than  hallucinations.  Of  the  13  cases 
which  have  been  under  personal  care,  no 
less  than  9  suffered  from  mania,  and  in 
5  of  these  it  came  on  after  attacks  of  epi- 
lepsy. Moral  insanity  is  of  frequent  oc- 
currence in  childhood,  and  hysteria  has 
been  frequently  noticed.  Fletcher  Beach 
(Jour,  of  Mental  Science,  July,  '98). 

Prognosis. — Eecovery  occurs  in  about 
70  per  cent,  of  cases.  When  recovery  fol- 
lows it  is  usually  only  after  several 
months,  from  six  months  to  a  year  being 
the  usual  duration  of  an  attack.  The 
recovery  is  rarely  sudden,  or  gradually 
progressive.  More  often  the  patient  im- 
proves for  a  time,  to  drop  back  in  a  day 
or  two  into  a  condition  of  excitement,  fol- 
lowed again  by  improvement,  and  thus 
recovery  is  reached  by  a  series  of  stages 
of  improvement  overlapping  a  series  of 
relapses.  In  other  cases  the  passing  off 
of  the  stage  of  excitement  is  followed 
by  one  of  depression,  out  of  which  the 
patient  gradually  awakes  to  his  normal 
mental  activity. 

Death  from  exhaustion  usually  occurs 
early.  Ordinarily  about  8  to  10  per  cent, 
of  cases  of  mania  die  from  exhaustion. 
Under  early  and  proper  treatment,  this 
proportion  should  be  much  diminished. 
Of  the  remainder  the  larger  proportion 
results  in  progressive  brain  degeneration, 
presenting  the  characters  of  consecutive 
dementia. 

Vacuolation  of  the  protoplasm  of  the 
nerve-cell  and  nucleus  and  pigmentary 
degeneration  observed  as  phenomena 
present  in  cases  of  acute  delirium.  T.  P. 
Prout  (Med.  News,  Aug.  18,  '94). 

Conclusions  regarding  prognosis  of 
acute  mania:  (1)  about  70  per  cent,  of 
all  cases  of  acute  mania  are  cured  after 
running  a  course  averaging  several 
months;  (2)  early  treatment  in  insanity 
hospitals  has  a  favorable  effect  upon  the 
course  of  the  disease;  (3)  a  family  his- 
tory of  insanity  does  not  necessarily 
make  the  prognosis  unfavorable;  (4) 


88 


INSANITY.    MANIA.  TREATMENT. 


cases  of  mania  occurring  as  sequelae  to 
disease — alcoholism  or  pregnancy — have 
a  favorable  prognosis,  both  as  regards 
duration  and  ultimate  cure;  (5)  cases 
due  to  slight  injury  of  the  head  usually 
recover;  (C)  the  return  of  the  men- 
strual flow  accompanying  an  improve- 
ment in  the  mental  condition  is  an 
indication  of  a  speedy  return  to  health; 
(7)  the  younger  the  patient,  the  greater 
is  the  hope  of  recovery;  (8)  recurrent 
mania  presents  a  bad  prognosis  for 
complete  and  lasting  cure;  (9)  where 
the  disease  is  of  long  standing  the  prob- 
ability of  recovery  is  poor;  (10)  the 
sudden  onset  of  great  maniacal  excite- 
ment is  an  unfavorable  symptom  except 
in  those  cases  following  pregnancy  or 
traumatism  of  the  head;  (11)  sudden 
stoppage  of  the  maniacal  excitement 
must  raise  the  fear  of  recurrent  mania 
or  of  early  relapse;  (12)  great  increase 
in  weight  before  the  beginning  of  the 
quiet  stage  must  be  similarly  inter- 
preted; (13)  the  more  severe  the  attack, 
the  poorer  is  the  prospect  of  complete  re- 
covery; (14)  paralysis  and  convulsions 
must  be  looked  upon  as  grave  complica- 
tions. Willerding  (Review  of  Insanity 
and  Nervous  Dis.,  Sept.,  '91). 

Treatment. — The  treatment  of  mania 
often  requires  great  tact,  perseverance, 
coolness,  and  command  of  therapeutic 
resources.  In  the  first  place,  in  case  of 
any  gravity,  home  treatment  is  generally 
impracticable.  The  noise,  the  motor  un- 
rest, the  constant  expert  attention  re- 
quired, and  the  violence  toward  others 
make  it  incumbent  in  most  cases  to  re- 
move the  patient  to  an  institution  for 
the  insane.  It  is  customary  in  most  hos- 
pitals for  the  insane  to  isolate  the  ma- 
niacal patient.  In  the  writer's  experi- 
ence this  sequestration  is  not  to  the 
patient's  advantage.  Keeping  the  pa- 
tient in  an  open  ward,  preferably  in 
bed,  in  the  presence  of  other  patients, 
constantly  suggesting  to  him  by  precept 
and  example  that  he  is  sick  and  requires 
treatment  will  usually  soon  quiet  the 
most  excitable  maniac.   It  may  be  neces- 


sary to  keep  one  or  more  attendants  by 
the  bedside  all  the  time,  to  prevent  him 
from  getting  up  and  running  about  and 
so  exhausting  himself.  A  bath,  clean 
linen,  and'  quiet,  tactful  nursing  will  do 
wonders  in  calming  the  excitement  and 
dissipating  the  delusions  of  the  maniac. 

Literature  of  '96-'97-'98. 

In  institutions  that  receive  a  large 
number  of  excited  patients  the  associa- 
tion of  the  same  in  large  observation- 
halls  is  accompanied  with  serious  dis- 
advantages. These  disadvantages  can  be 
relieved:  (a)  by  a  separate  observation- 
room  for  the  extremely  disturbed  cases, 
and,  eventually,  a  third  for  quiet  and 
orderly  patients,  separate  from  the  re- 
ceiving-ward properly  so-called;  (&)  by 
a  subdivision  of  the  observation-ward, 
and,  finally,  by  removing  the  most 
affected  patients  into  single  rooms  of  a 
home-like  appearance.  By  suitable  archi- 
tectural arrangements  permitting  this 
separation  into  single  rooms,  together 
with  thorough  watching  and  care,  and 
the  use  of  the  treatment  in  bed;  isola- 
tion in  this  form  is  to  be  considered  as 
a  valuable  therapeutic  method.  Isolation 
for  other  than  therapeutic  reasons  can 
in  this  way  be  reduced  to  a  minimum, 
but  cannot  as  yet  be  altogether  dis- 
pensed with.  For  certain  cases  rooms  of 
a  stronger  construction  should  be  pro- 
vided. Heilbronner  (Amer.  Jour.  Insan., 
Apr.,  '97). 

In  the  treatment  of  mania  no  restraint 
and  rest  in  bed  recommended,  except 
when  the  strong-room  is  absolutely 
necessary.  Baths,  bromide  and  chloral, 
may  be  given,  but  for  severe  excitement 
or  great  sleeplessness  an  injection  of 
hyoscine  is  necessary.  Good  nourish- 
ment should  be  given,  but  no  beer,  wine, 
or  spirits.  Baths  at  a  temperature  of 
about  23°  C.  given  for  two  to  five  hours 
as  a  means  of  quieting  the  patient,  with 
cold  compresses  to  the  neck.  When  the 
excitement  is  very  great,  instead  of  the 
baths  a  damp  sheet  should  be  used.  In 
the  evening  45  to  75  grains  of  bromide 
of  potassium  are  given,  and  two  to  three 
hours  later  30  to  45  grains  of  chloral. 
After  ten  days,  if  the  patient  is  quieter, 


INSANITY.    MANIA.  TREATMENT. 


89 


the  bromide  is  lessened  and  the  chloral 
is  only  given  occasionally,  and  sulphonal 
or  trional  are  substituted.  Where  bro- 
mide and  chloral  are  useless,  laudanum 
in  increasing  doses  is  given.  Magnan 
(Rev.  de  Psych.,  July,  >97). 

The  general  indications  in  the  treat- 
ment of  delirium  are,  first,  to  secure 
sleep;  second,  to  overcome  motor  unrest; 
third,  to  prop  up  and  maintain  the  pa- 
tient's vitality  by  contributing  to  his 
nutrition;  and,  fourth,  to  discover  and 
remove  the  cause  upon  which  the  de- 
lirium is  dependent,  Collins  (Med. 
News,  Feb.  26,  '98). 

Careful  attention  must  be  paid  to  the 
bodily  functions.  A  useful  preliminary 
is  a  large  rectal  lavement,  to  remove 
fsecal  accumulations  and  prevent  soiling 
of  the  bed.  Feeding  with  nutritious  food 
is  of  the  first  importance.  Maniacs 
usually  eat  ravenously  anything  offered 
them.  Care  should  be  taken  to  prevent 
overloading  the  stomach  with  indigest- 
ible food.  In  cases  where  the  pulse  is 
weak  and  rapid,  the  addition  of  a  moder- 
ate quantity  of  alcohol  is  often  useful. 
Milk  and  eggs,  with  beef-juice,  or  partly 
predigested  beef-powder,  and  some  of  the 
starchy  invalid  foods  are  perhaps  the 
best  form  in  which  to  introduce  nourish- 
ment. 

In  cases  of  very  active  mania,  a  warm 
bath,  with  effusion  of  cold  water,  some- 
times has  such  a  calmative  effect  that 
patients  who  before  refused  food  then 
took  it  freely.  Binswanger  (Centralb. 
f.  Nervenh.,  Mar.,  '91). 

Sleep  must  be  secured.  If  it  does  not 
follow  the  measures  here  recommended 
within  a  reasonable  time,  some  hypnotic 
must  be  given.  Among  the  hypnotics 
least  likely  to  disturb  digestion  or  de- 
press the  appetite  are  bromide  of  potas- 
sium, chloral,  hyoscine,  sulphonal,  and 
trional.  Clouston  highly  recommends 
chloral,  30  grains,  with  10  minims  of  the 
tincture  of  cannabis  Indica.  A  combina- 
tion of  bromide  of  sodium  and  chloral, 


of  each,  15  grains,  with  15  minims  of 
tincture  of  hyoscyamus  is  also  an  excel- 
lent calmative.  In  cases  of  great  weak- 
ness and  rapidity  of  the  heart's  action, 
digitalis,  strophanthus,  or  strychnine 
may  be  added  to  the  bromide-and-chloral 
mixture.  Paraldehyde  is  a  valuable  hyp- 
notic in  cases  with  depression.  It  is 
given  in  doses  of  1/2  drachm  to  1  drachm 
in  1/2  ounce  of  whisky,  diluted  with  a 
little  water.  It  usually  produces  sleep 
within  an  hour.  A  bottle  of  ale  or  beer 
is  often  an  excellent  hypnotic. 

Opium,  which  is  so  useful  in  melan- 
cholia is  generally  contra-indicated  in 
mania.  The  brain-hypergemia  is  simply 
increased  by  the  drug,  and  the  symptoms 
heightened.  In  the  late  stages,  however, 
where  there  is  brain-exhaustion  and  the 
descent  into  dementia  seems  imminent, 
opium  sometimes  pulls  the  patient  to- 
gether and  enables  him  to  recover. 

Opium  or  morphine  recommended  in 
the  acute  stages  of  mania.  The  heart 
should  be  sustained  by  digitalis.  In 
cases  of  hyperemia  nothing  is  better 
than  ergotine.  In  obtaining  sleep  and 
inducing  bodily  quiet,  warm  and  pro- 
longed baths,  also  hyoscine.  Krafft- 
Ebing  (Inter,  klin.  Rundschau,  May  25, 
June  1,  8,  25,  29,  '90). 

"Chlorobrom,"  a  mixture  of  bromide 
of  potassium  and  chloralamid,  is  also  a 
satisfactory  hypnotic  in  mania.  It  does 
not  produce  depression  or  derange  di- 
gestion. 

In  mania,  chloralose,  in  doses  of  from 
1 3/4  to  15  V2  grains;  preferably  given  in 
solution  in  boiling  water.  Sedative  effect 
in  from  fifteen  to  twenty  minutes  after 
taking  the  drug.  Haskovec  (Revue 
Neurol.,  Oct.,  '94). 

Neutral  duboisine  sulphate  an  excellent 
sedative  in  all  psychical  and  motor  agita- 
tion. Sleep  produced  similar  to  physio- 
logical slumber.  Dose  varies  from  1/1S0 
to  x/40  grain.  Loicano  and  Masuro  (Med. 
Standard,. May,  '95). 


90 


INSANITY.  MANIA. 


GENERAL  PARESIS. 


Literature  of  '96-'97-'98. 

In  hypodermic  doses  of  1/,50  to  1/7B 
grain  scopolamine  proved  a  good  hyp- 
notic in  paroxysmal  excitement,  but  not 
in  habitual  insomnia.  It  is  especially 
useful  in  acute  mania.  Tomasini  (Brit. 
Med.  Jour.;  Epitome,  Dec.  4,  '97). 

Duboisine  sulphate,  by  the  mouth,  and 
also  hypodermically  in  doses  of  1/100  to 
V32  grain,  used  in  all  cases  of  excitement  ; 
in  acute  mania  its  use  was  not  followed 
by  any  beneficial  results;  single  doses 
produced  quiet  for  a  time,  but  this  was 
followed  by  more  excitement.  In  de- 
lusional mania  it  was  only  used  for  out- 
bursts of  excitement,  and  was  entirely 
satisfactory.  In  general  paralysis  the 
drug  was  used  both  occasionally  and 
continuously,  with  satisfactory  results. 
In  melancholia  bad  results  were  seen;  in 
no  case  was  there  any  relief,  and  in  some 
cases  the  excitement  was  increased,  and 
there  was  a  tendency  to  syncope,  with 
hallucinations  of  sight  and  hearing. 
Used  occasionally  in  dementia  it  gave 
satisfactory  results,  with  rest  at  night. 
The  danger  of  the  drug  is  from  cardiac 
failure,  if  given  continuously.  It  should 
be  used  only  in  physically-healthy  per- 
sons. On  the  whole,  the  drug  is  prefer- 
able to  hyoscine  or  hyoscyamine,  as  the 
quiescent  state  induced  is  of  longer  dura- 
tion, and  there  is  less  prostration.  Skeen 
(Journal  of  Mental  Science,  July,  '97). 

Hydrobromide  of  hyoscine  preferred  to 
the  hydrochloride.  It  is  given  in  doses 
of  Vs  to  Vto  grain.  In  cases  of  mental 
excitement  with  delirium  and  destruct- 
ive tendencies,  especially  in  periodic 
mania,  it  is  of  great  value,  also  in  the 
delirium  of  alcoholics.  In  melancholia 
agitata  as  well  as  in  other  cases  of 
sleeplessness,  hyoscine  often  produces 
quietude  when  all  other  means  fail.  On 
the  other  hand,  it  is  not  adapted  for  all 
cases  of  an  hysterical  nature,  and  espe- 
cially in  affections  which  require  a  con- 
stant use  of  sedatives.  Marked  valvular 
trouble  and  fatty  heart  contra-indicate 
it.  Doerner  (Therap.  Monats.,  June, '98) . 

After  the  acute  stage  has  passed  the 
physical  strength  returns,  and  the  brain 
begins  to  return  to  its  normal  activity, 


great  care  is  necessary  to  prevent  relapses. 
All  sources  of  irritation  should  be  kept 
from  the  patient,  visits  of  friends  should 
not  be  allowed  too  soon  or  too  frequently, 
and  he  should  be  kept  under  close  obser- 
vation until  the  normal  mental  stability 
is  re-established. 

Group  IV.  Psychoses  due  to  Mi- 
croscopic Structural  Alterations 
in  the  Brain  (Primarily  Probably 
Nutritional  or  Toxic), 

General  Paresis. 

Definition.  —  General    paresis    is  a 
I  chronic,  progressive,  diffuse,  structural 
alteration  of  the  cerebral  tissue,  with  in- 
I  volvement  of  the  cortical  and  meningeal 
blood-  and  lymph-  vessels,  attended  by 
I  characteristic  psychical  and  motor  dis- 
!  turbances.    The  disease  is  incurable  and 
leads  to  death  usually  within  three  years. 

Symptoms   and    Course. — Xo  single 
symptom  can  be  regarded  as  diagnostic 
I  of  general  paresis,  even  in  the  advanced 
stages.     The  diagnosis  must  be  made 
1  from  a  study  of  certain  concomitant 
symptoms,  partly  psychical  and  partly 
physical.    Of  the  latter,  the  motor  dis- 
1  turbances  are,  as  the  various  names  given 
I  to  the  disease  indicate,  the  most  char- 
acteristic. 

Among  the  early  psychical  symptoms 
are  irritability  and  especially  an  in- 
stability of  the  moral  and  mental  char- 
j  acter.  The  subject  is  easily  disturbed, 
emotional,  of  variable  moods.  His  mem- 
ory, especially  for  recent  occurrences,  be- 
comes defective.  He  forgets  dates,  ap- 
pointments, mislays  valuable  documents 
or  other  articles.  The  moral  sense  is 
often  perverted.  He  loses  that  delicate 
sense  of  propriety  by  which  his  previous 
life  has  been  guided.  He  becomes  un- 
conventional, consorts  with  drunkards 
and  lewd  females,  makes  indecent  pro- 
posals to  respectable  women  of  his  ac- 


INSANITY.    GENERAL  PARESIS.  SYMPTOMS. 


91 


quaintance,  indulges  in  a  latitude  of 
speech  and  action  not  tolerated  by  the 
conventions  of  the  social  stratum  to 
which  he  belongs;  all  this  without  recog- 
nizing any  impropriety  in  it.  He  may 
make  a  public  merit  of  his  sociological 
study  of  the  nude  in  brothels,  and  of  his 
compounding  with  liars  and  perjurers. 
He  may  violate  public  decency  by  ex- 
posure of  his  genitals  in  the  street,  or 
show  a  coarse  disregard  for  his  own 
household  by  defecating  in  bed  or  uri- 
nating on  the  carpet  in  his  room. 

There  is  progressive  inability  to  con- 
centrate the  attention.  With  the  failure 
in  memory,  incidents,  real  or  imaginary, 
are  embellished  with  fanciful  details,  the 
truth  of  which  is  asserted  and  maintained 
with  vigor,  and  all  doubts  are  actively 
and  often  angrily  combated. 

The  prevailing  character  of  the  psy- 
chical manifestations  is  one  of  exaltation. 
Cases  occur  not  infrequently,  however, 
in  which  the  key-note  throughout  the 
whole  course  of  the  disease  is  depression. 
In  some  instances  the  diagnosis  of  melan- 
cholia would  be  justified  if  the  psychical 
symptoms,  alone  are  taken  into  consider- 
ation. Delusions  of  persecution  may  also 
be  present,  but  are  generally  attended  by 
expansive  delusions. 

Delusions  of  grandeur  are  present  in 
most  cases  of  general  paresis,  although 
they  cannot  be  regarded  as  essential  or 
pathognomonic.  Many  cases  of  general 
paresis  run  their  entire  course  without 
manifesting  exaltation  or  expansive  de- 
lusions at  any  time. 

The  delusions  of  grandeur  are  not  only 
unreasonable,  but  the  patient's  reasons 
for  his  extravagant  beliefs  are  either  in- 
adequate or  he  does  not  give  any  reasons. 
While  his  imagination  seems  to  be  vivid, 
as  shown  in  his  delusions,  it  is,  in  fact, 
decreased.  His  delusions  are  so  unre- 
stricted that  the  most  modest  healthy 


imagination  at  once  recognizes  their  ab- 
surdity. 

[There  are  no  limits  to  the  wealth,  the 
power,  or  the  accomplishments  of  the 
general  paretic  during  the  height  of  his 
delusions.  One  patient  was  going  to 
build  a  railroad  from  Home  to  Chicago 
for  the  sole  purpose  of  bringing  the  Pope 
to  see  the  World's  Fair;  another  had 
such  acute  vision  that  he  could  see  a 
thousand  miles  without  any  difficulty; 
another  owned  the  entire  United  States, 
France,  and  Spain,  with  outlying  prov- 
inces in  China,  India,  and  South  America. 
He  could  have  England,  also,  but  didn't 
want  it  so  long  as  the  queen  lived. 
George  H.  Rohe.] 

These  delusions  are  rarely  fixed;  that 
is  to  say,  they  do  not  possess  the  perma- 
nent character  of  the  delusions  of  para- 
noia. While  there  is  a  general  sameness 
of  the  main  feature, — the  expansiveness 
of  the  delusion, — the  individual  delu- 
sions constantly  vary. 

As  the  disease  progresses,  dementia 
becomes  more  and  more  marked.  The 
destruction  of  the  intellectual  faculties  is 
so  complete  that  toward  the  last  even  the 
delusions  disappear.  This  progressive 
dementia  goes  hand  in  hand  with  the 
physical  deterioration  of  the  powers,  so 
that  when  at  last  death  comes  to  end  the 
scene,  the  vital  machine  may  be  said  to 
go  to  pieces  like  the  "deacon's  one-hoss 
shay." 

One  of  the  earliest  physical  symptoms 
is  persistent  insomnia,  not  yielding  to 
hygienic  or  medicinal  agencies.  It  is 
often  accompanied  by  intense  and  fre- 
quently-recurring hemicrania.  The 
sleeplessness  and  pain  are  believed  by 
many  to  indicate  intracranial  pressure; 
but  this  is  not  absolutely  certain. 
Ophthalmoscopic  examination  fails  to 
show  intracranial  pressure.  In  other 
cases  there  is  an  uncontrollable  desire  to 
sleep.  The  patient  falls  asleep  in  the 
midst  of  his  occupation  or  in  company. 


d2 


INSANITY.    GENERAL  PARESIS.  SYMPTOMS. 


Early  symptoms  also  are  losses  of  con- 
sciousness varying  in  degree  from  mo- 
mentary dizziness  to  apparently  true 
apoplectic  attacks.  They  are  present  in 
nearly  every  case  and  are  important  diag- 
nostic signs.  While  they  are  frequent 
and  severe  in  the  advanced  stages,  they 
are  often  the  first  indication  of  serious 
cerebral  disease.  After  severe  attacks 
there  may  be  hemiplegia,  which,  how- 
ever, usually  disappears  in  a  few  hours 
or  days.  These  attacks  are  evidently 
not  due  to  rupture  or  thrombus  of  the 
cerebral  vessels,  but  probably  to  circum- 
scribed oedema  of  the  brain,  which 
rapidly  passes  away. 

[I  have  seen  cases  of  general  paresis 
in  advanced  stages  with  apoplectic  at- 
tacks, sometimes  with  convulsions,  fol- 
lowed by  profound  coma,  contracted 
pupils,  and  Cheyne-Stokes  respiration, 
and  after  predicting  a  fatal  termination 
of  the  case  within  two  hours  has  had 
the  patients  still  in  hospital  three 
months  later.    George  H.  Rohe.] 

Convulsions  epileptiform  in  character, 
may  also  be  present  as  early  symptoms, 
but  are  usually  met  with  in  the  later 
stages. 

Sometimes  the  apoplectic  attacks  are 
due  to  internal  hemorrhagic  pachy- 
meningitis, and  in  these  cases  death 
often  follows  soon  after  the  stroke. 

Literature  of  'dG-W-'dS. 

Ordinary  cerebral  haemorrhage  consti- 
tutes the  gross  lesion  in  the  majority  of 
cases  of  paralytic  insanity.  It  is  also 
very  common  in  senile  insanity. 

Multiple  minute  recent  blood-extrava- 
sations are  to  be  observed  with  consider- 
able frequency  in  microscopical  sections 
of  the  brain  from  the  insane.  Most  of 
such  haemorrhages  are  capillary  ruptures 
of  very  small  size.  When  they  take 
place  from  larger  vessels,  the  blood  is 
often  merely  poured  into  the  adventitial 
lymph-space.  W.  F.  Robertson  (Edin- 
burgh Med.  Jour.,  Mar..  '9.G). 


Frequent  among  the  early  symptoms 
are  those  connected  with  the  innervation 
of  the  iris.  The  pupil  is  usually  irregu- 
lar, mostly  dilated,  more  rarely  con- 
tracted, in  the  fewest  cases  normal  in 
diameter.  The  pupils  of  the  two  sides 
often  vary  in  size  and  reaction.  The  re- 
action to  light  and  sensation  may  be  re- 
tarded or  entirely  abolished.  The  Argyll- 
Robertson  pupil,  so  characteristic  of 
tabes,  is  also  a  frequent  symptom  of  gen- 
eral paresis.  It  probably  depends  upon 
similar  degenerative  processes  as  in  the 
former  disease.  It  is  said  that  the  ocular 
symptoms, — inequality  of  pupils,  myosis, 
and  Argyll-Robertson  pupil  have  been 
noted  several  years  before  the  outbreak 
of  the  mental  disturbances. 

Two  per  cent,  of  all  insane  persons 
have  lost  the  color-sense.  The  sense  for 
violet  is  lost  in  about  10  per  cent,  of  the 
cases,  being  almost  exclusively  limited 
to  various  forms  of  dementia  (general 
paresis,  senile  dementia,  organic  de- 
mentia). This  loss  of  color-sense  is  gen- 
erally accompanied  by  a  diminution  of 
acuteness  of  vision  and  the  sense  of  light. 
L.  Cronstel  (These  de  Paris,  '93). 

Literature  of  '96-'97-'98. 

Inequality  of  the  pupils  is  at  times  met 
with  in  healthy  individuals,  and  it  occurs 
in  general  diseases  of  the  most  diverse 
nature.  In  3010  cases  of  dementia  para- 
lytica the  pupillary  reaction  to  light  was 
lost  or  diminished  in  08  per  cent.  The 
Argyll-Robertson  pupil  of  great  diagnos- 
tic importance  in  general  paralysis,  and 
is  one  of  the  very  early  manifestations 
of  the  disease.  It  is  usually  bilateral ; 
a  continuous  unilateral  loss  of  the  light 
reflex  is  very  rare.  The  first  change  is 
generally  a  diminution  of  the  reaction  to 
light,  then  a  total  loss,  followed  by 
paresis  and  paralysis  of  reaction  to  ac- 
commodation. Siemerling  (BerL  klin. 
Woch.,  No.  44,  '90). 

Other  motor  symptoms  are  changes  in 
the  deep  reflexes.  The  patellar  reflex  is 
most  often  increased,  but  may  be  normal, 


INSANITY.  GENERAL 


PARESIS.  SYMPTOMS. 


93 


diminished,  or  absent.  It  has  no  diag- 
nostic significance  except  in  connection 
with  other  physical  or  mental  symptoms. 

The  facial  muscles  often  show  signs  of 
involvement.  A  fibrillary  tremor  or 
twitching  of  the  muscles  about  the 
mouth,  sometimes  a  spastic  condition  of 
single  muscles  or  groups  of  muscles 
about  the  face,  loss  of  expression  from 
paresis  of  certain  muscle-groups  may  be 
present.  On  protruding  the  tongue  the 
organ  is  tremulous  or  protruded  in  a 
spastic  or  jerky  manner.  Tremor  of  the 
hands  is  also  present  as  a  symptom  of  the 
advanced  stage.  The  writing  becomes 
irregular  and  "shaky." 

The  speech  is  jerky,  slow,  or  "scan- 
ning." In  advanced  cases  it  becomes 
slurring.  Syllables  are  dropped  or  re- 
peated. Certain  words  are  pronounced 
with  difficulty,  the  test  phrase  "truly 
rural"  usually  running  into  "toory 
looral."  Later  the  speech  becomes  indis- 
tinct and  finally  degenerates  into  an  in- 
articulate sound,  in  which  no  words  can 
be  distinguished.  The  early  speech- 
defects  are  probably  due  to  fibrillary 
tremor  or  twitchings  of  the  tongue  and 
lips.   The  later  ones  are  paretic  in  origin. 

Literature  of  '96-'97-'98. 

In  the  earlier  stages  of  general  paresis, 
the  physical  signs  are  the  most  marked. 
Chief  among  them  are:  (1)  the  stam- 
mering or  tremulous  speech;  (2)  the 
tremor  of  the  facial  muscles  and  of  the 
tongue;  (3)  the  pupillary  symptoms; 
(4)  the  change  in  the  handwriting;  (5) 
the  exaggeration  or  the  absence  of  the 
reflexes.  The  diagnosis,  however,  can 
only  be  established  if  some  one  or  more 
of  these  signs  are  associated  with  mental 
symptoms.  Any  departure  from  the 
standard  of  thought  and  action  that  the 
individual  has  established  for  himself 
should  always  be  regarded  with  sus- 
picion, as  should  also  any  changes  in  his 
bearing  that  are  not  in  keeping  with  his 
position  in  life.   Defective  judgmenl  and 


especially  defective  memory  are  common 
changes.  The  early  stages  of  the  disease 
may  be  readily  confounded  with  other 
conditions.  The  most  common  is  cerebral 
neurasthenia.  B.  Sachs  (N.  Y.  Med. 
Jour.,  July  2,  '98). 

The  lines  of  expression  in  the  face  be- 
come obliterated  in  the  later  stages  of 
paresis,  but  this  sign  can  at  times  be 
noticed  among  the  early  symptoms  on 
careful  examination. 

An  early  symptom  is  retention  of  the 
urine,  which  is  due  to  loss  of  contractile 
power,  or  of  reflex  sensibility  in  the  ves- 
ical walls.  The  overdistended  bladder 
dribbles  urine.  This  may  be  mistaken 
for  a  paralytic  condition.  In  the  ad- 
vanced cases  there  is  dribbling  of  urine 
and  involuntary  escape  of  faeces  from 
relaxation  of  the  sphincters. 

An  annoying  symptom  of  cortical  irri- 
tation is  a  constant  grinding  of  the  teeth. 
This  is  so  often  present  in  general  pare- 
sis that  it  is  considered  by  some  authors 
as  pathognomonic,  but  it  also  occurs  in 
some  cases  of  simple  dementia. 

The  gait  in  the  early  stages  is  spastic 
or  ataxic.  In  advanced  cases  it  becomes 
slouching  or  dragging. 

In  the  advanced  stages,  coincident 
with  the  progressive  dementia,  is  in- 
creased motor  debility.  Tremors  or 
twitchings  give  place  to  paresis  and 
these  again  to  complete  paralytic  condi- 
tions. The  patient  is  no  longer  able  to 
keep  on  his  feet,  and  after  a  time  he 
becomes  bedfast.  The  power  of  articu- 
lation is  lost  and  the  voice  becomes  an 
inarticulate  moan,  extremely  distressing 
to  the  hearer. 

Mastication  of  food  is  forgotten  and 
masses  too  large  to  pass  down  the  oesoph- 
agus are  partly  swallowed  and  often 
cause  asphyxia  by  compressing  the 
trachea. 

Vasomotor  disturbances  are  frequent. 


94 


INSANITY.    GENERAL  PARESIS.  DIAGNOSIS. 


The  innervation  of  the  vessels  is  dimin- 
ished and  there  follows  dilatation  of  the 
superficial  vessels,  redness  or  blueness  of 
the  skin,  oedema  and  cyanosis  of.  the 
peripheral  members,  and  diminution  of 
blood-pressure. 

The  haemoglobin  and  red  corpuscles  in 
general  paralysis  vary  with  the  body- 
weight,  the  haemoglobin,  however,  dimin- 
ishing more  than  the  red  cells.  They 
both  decrease  in  the  early  stage,  are  sta- 
tionary in  the  so-called  second  stage, 
and  fall  again  in  the  third.  Winckler 
(Inaug.  Dissert.,  '91). 

Literature  of  '96-'97-'98. 

In  general  paralysis:  1.  The  haemo- 
globin and  red  corpuscles  are  always 
diminished. 

2.  The  specific  gravity  falls  slightly 
below  the  normal. 

3.  Most  cases  show  a  slight  leuco- 
cytosis,  amounting  on  an  average  to 
about  22  per  cent,  above  the  normal. 
Early  cases  may  have  no  leucocytosis 
whatever. 

4.  In  the  differential  count  a  decrease 
is  found  in  the  lymphocytes  along  with 
a  marked  increase  in  the  large  mononu- 
clear cells.  The  eosinophiles  in  a  few 
cases  are  very  numerous.  J.  A.  Capps 
(Amer.  Jour.  Med.  Sci.,  June,  '96). 

Sometimes  there  are  punctiform  ex- 
travasations of  blood  in  the  skin,  and 
even  actual  haemorrhages  from  the  mu- 
cous surfaces,  as  from  the  bowel. 

Consequent  upon  the  defective  inner- 
vation, combined  with  external  mechan- 
ical influences  (traumatisms,  prolonged 
pressure,  etc.),  trophic  changes  occur. 
Othematoma  and  bed-sores  are  often 
noticed,  the  latter  especially  when  the 
patients  have  become  bedfast. 

The  course  of  general  paresis  is,  as  a 
rule,  steadily  progressive.  Cases  occur 
in  which  there  are  remissions,  sometimes 
lasting  for  months,  but,  except  in  the 
earliest  stages,  when  the  diagnosis  must 
be  regarded  as  somewhat  uncertain,  no 


cases  of  permanent  arrest  of  the  disease 
have  been  recorded. 

Literature  of  '96-'97-'98. 

Changes  that  have  appeared  in  the 
clinical  picture  of  progressive  paralysis 
of  the  insane  in  the  last  thirty  years  dis- 
cussed. In  1880  was  found  55  typical 
cases  and  37  of  the  form  characterized  by 
dementia.  In  194  cases  observed  since, 
the  typical  form  occurred  in  37  cases  and 
dementia  in  70  cases.  The  greater  fre- 
quency of  marked  remissions  also  noted, 
many  of  the  patients  being  able  to  re- 
sume their  occupation  from  time  to  time, 
even  after  the  physical  signs  had  been 
pronounced.  The  disease,  in  spite  of 
its  milder  character,  appears  to  have 
become  much  more  frequent,  particularly 
among  the  women;  the  present  pro- 
portion being  about  4  men  to  1  woman 
and,  in  cases  developing  early  in  life, 
the  sexes  are  almost  equally  affected. 
Children  are  more  frequently  affected 
than  formerly,  and  this  appears  to  be 
due  to  the  greater  frequency  of  heredi- 
tary syphilis.  Mendel  (Neurol.  Centralb., 
Nov.  15,  '98). 

The  average  duration  of  the  disease  is 
j  between  two  and  three  years.  In  some 
|  cases  it  has  been  known  to  continue 
longer,  and  cases  are  on  record  in  which 
the  duration  is  said  to  have  been  twenty 
years.  On  the  other  hand,  it  sometimes 
runs  an  acute  course,  ending  in  death  in 
a  few  months. 

Diagnosis. — Cerebral  syphilis,  tabes, 
chronic  alcoholism,  and  cerebral  neuras- 
thenia must  be  differentiated  from  gen- 
eral paresis  in  its  early  stages.  In  syphi- 
lis there  are  more  frequently  symptoms 
referable  to  gross  brain-lesions,  ptosis, 
and  other  monoplegia^  or  more  persistent 
hemiplegia  than  in  paresis.  At  times 
the  diagnosis  is  impossible  during  life. 
Tabes  has  strongly  marked  motor  and 
sensory  symptoms  not  usually  present  in 
general  paresis,  although  they  may  com- 
i  plicate  the  latter. 


INSANITY.    GENERAL  PARESIS.  DIAGNOSIS. 


95 


As  regards  paresis,  syphilis  produces 
a  pseudoparesis  which  is  very  hard  to 
distinguish  from  true  general  paralysis. 
True  general  paralysis,  where  syphilis  is 
but  a  concomitant  element,  or  at  best 
but  a  secondary  cause,  is  not  in  the  least 
influenced  by  specific  treatment,  while 
in  syphilitic  pseudoparesis  a  recovery 
may  be  anticipated  if  organic  structural 
changes  have  not  been  produced.  A. 
Morel-Lavallee  (Gaz.  des  Hop.,  Oct.  19, 
'89) . 

Literature  of  '96-'97-'98. 

Form  of  pseudogeneral  paresis  accom- 
panying diseases  of  the  liver.  A  sea- 
captain,  of  alcoholic  habits  subject  to 
attacks  of  jaundice,  was  suddenly  taken 
with  difficulty  in  walking,  and  had  an 
apoplectiform  attack,  following  which 
he  remained  in  an  apathetic  state,  and 
had  some  motor  disturbances  of  the 
tongue  and  lips,  in  the  form  of  a  suction 
movement.  His  speech  was  slow  and 
rather  scanning,  similar  to  that  of  dis- 
seminated sclerosis.  A  diagnosis  had 
been  made  of  general  paresis,  with  which 
the  writer  did  not  agree,  as  fibrillary 
twitchings  of  the  tongue  and  lips  were 
absent  and  the  pupils  showed  no  in- 
equality. The  examination  of  the  urine 
showed  the  presence  of  urobilin,  and  a 
diagnosis  was  made  of  mental  derange- 
ment secondary  to  disease  of  the  liver. 

This  diagnosis  was  justified  by  the  al- 
most complete  disappearance  of  the  men- 
tal symptoms  following  an  amelioration 
in  the  disease  of  the  liver,  and  by  the 
fact  that  a  relapse  of  the  mental  condi- 
tion occurred  on  the  patient's  relapsing 
into  a  condition  of  grave  icterus,  in 
which  he  succumbed.  Joffroy  (Gaz. 
Med.  de  Paris,  '96).. 

Chronic  alcoholism  sometimes  pre- 
sents symptoms  resembling  early  general 
paresis,  but  the  ocular  symptoms  of  the 
latter  are  absent.  The  tremor  and  epi- 
leptiform attacks  and  mental  manifesta- 
tions are  easily  mistaken  for  the  same 
classes  of  symptoms  in  general  paresis. 
This  is  especially  the  case  where  the  de- 
lusions are  of  the  depressive  form.  In 
alcoholic  insanity,  however,  there  are 


more  frequently  delusions  of  suspicion, 
and,  in  married  persons,  delusions  of 
infidelity  on  the  part  of  the  spouse, 
which  may  lead  to  criminal  acts. 

The  insomnia,  loss  of  memory,  and 
hypochondriac  sensations  of  neuras- 
thenia may  be  mistaken  for  general  pare- 
sis. In  many  cases  it  is  only  when  the 
progressive  character  of  the  disease  is 
noted  that  a  positive  diagnosis  can  be 
made.  In  neurasthenia  delusions  of 
grandeur  do  not  occur,  and,  in  place  of 
the  sense  of  well-being  expressed  by  the 
paretic,  the  most  minute  details  of 
physical  symptoms  are  given.  Thus,  the 
neurasthenic  can  usually  give  an  accurate 
account,  with  most  wearisome  details,  of 
his  gastric,  abdominal,  cardiac,  or  cere- 
bral symptoms.  The  paretic,  if  he 
notices  these  at  all,  declares  them  of  no 
consequence.  Neurasthenia  may  be  de- 
fined symptomatically,  as  a  morbid  sensi- 
tiveness, while,  on  the  other  hand,  paresis 
is  an  abnormal  lack  of  sensitiveness  to 
morbid  impressions. 

A  subject  presenting  the  symptoms 
heretofore  given,  namely:  persistent  in- 
somnia, with  headache,  a  gradual  change 
in  his  moral  nature,  loss  of  regard  for 
I  public  opinion;  peculiarities  in  the  psy- 
chical life,  coming  on  so  gradually  as  not 
to  attract  attention  until  opinions  or 
acts  more  peculiar  than  usual  are  mani- 
fested; delusions,  either  of  persecution, 
depression,  or  grandeur;  irregular,  di- 
lated, or  contracted  pupils,  with  absence 
of  the  usual  reactions  to  light  and  sensa- 
tion; the  persistence  of  the  accommoda- 
tion-reflex, heightened  patellar  reflex  and 
attacks  of  faintness,  attacks  of  uncon- 
sciousness or  epileptiform  convulsions 
should  be  viewed  as  a  beginning  case  of 
general  paresis.  If  the  usual  speech- 
defects  characterizing  this  disease  are 
present,  the  diagnosis  may  be  regarded 
as  reasonably  certain. 


96 


INSANITY.  GENERAL 


PARESIS.  CAUSATION. 


In  advanced  cases  of  general  paresis  no 
difficulty  should  arise  in  diagnosis. 

Causation. — General  paresis  —  paretic 
dementia,  general  paralysis  of  the  insane 
— is  a  disease  of  the  middle  period  of  life, 
rarely  beginning  before  the  thirty-fifth 
and  still  more  rarely  after  the  fiftieth 
years  of  life.  Cases  among  children  or 
in  old  persons  are,  however,  not  un- 
known. It  attacks  by  preference  persons 
in  the  higher  walks  of  life,  but  among 
these  is  found  especially  in  such  as  have 
more  or  less  irregular  habits.  Syphilis 
is  regarded  by  many  authorities  as  the 
most  prominent  single  cause,  but  cases 
frequently  occur  in  which  no  evidence  of 
syphilitic  infection  can  be  found.  Men- 
tal stress,  especially  when  associated  with 
intemperance,  venereal  excesses,  or  other 
irregular  habits  are  often  found  as  pre- 
cedent conditions  and  may  perhaps  be  re- 
garded as  etiological  factors. 

Cerebral  syphilis  and  general  paralysis 
must  be  considered  as  two  distinct  affec- 
tions, which  may  co-exist  in  the  same 
person,  but  run  their  course  independ- 
ently from  each  other.  There  exists  no 
observation  which  establishes  without 
doubt  that  syphilis  can  produce  general 
paralysis.  Regnier  (La  Semaine  Med., 
Aug.  10,  '90). 

Among  personal  cases  of  paralysis 
about  80  per  cent,  of  syphilitics  found. 
General  paralysis  appeared  about  twelve 
or  thirteen  years  after  infection,  and  it 
appeared  the  sooner  the  less  specific 
treatment  there  had  been.  Most  of  the 
syphilo-paralytics  do  not  manifest  the 
external  signs  of  syphilis,  and  so  it  is 
with  their  descendants.  On  an  average, 
the  paralytic  syphilitics  are  younger 
than  the  paralytic  non-syphilities,  and 
among  the  syphilo-paralytics  the  young- 
est are  those  whose  syphilis  is  the  most 
recent.  Regis  (I. a  Semaine  MGd.,  Aug. 
10,  '90). 

Paresis  is  essentially  a  disease  of  this 
century,  and  one  which  is  increasing. 
In  the  tendency  to  mental  overexertion 
and  in  excesses  in  Yencre  ct  liavchn  are 
found     important     etiological  factors. 


Krafft-Ebing  (Wiener  med.  Presse,  Nov. 
17,  '90). 

The  two  most  important  etiological 
factors  in  precocious  general  paresis  are 
heredity  and  congenital  syphilis.  J. 
Wigles worth  (Brit.  Med.  Jour.,  Mar.  25, 
'93). 

Analysis  of  two  hundred  cases  in 
KrafTt-Ebing's  clinic.  Conclusion  that 
syphilis  is  the  chief  cause  of  general 
paresis.  Heredity  seemed  to  be  concerned 
in  11  per  cent,  of  cases.  Psychical 
causes  could  not  be  discovered.  In  13 
cases  there  was  a  history  of  traumatism, 
in  19  alcoholic  excesses.  Out  of  175  cases 
with  complete  histories,  56  per  cent,  gave 
a  positive  history  of  syphilis,  and  25  per 
cent,  a  probable  history.  In  seventy- 
eight  cases  the  period  from  infection  to 
the  symptoms  of  paresis  varied  from  two 
to  twenty-nine  years.  Hirschl  (Wien. 
klin.    Rundschau,  No.  45,  '95). 

Literature  of  '96-'97-'98. 

In  forty-one  cases  of  paretic  dementia 
in  children,  syphilis  could  be  traced  in 
87.8  per  cent.  Zappert  (Therap.  Woch., 
iv,  289,  '97). 

Report  to  the  Asylums  Committee  of 
the  London  County  Council  showing 
that  in  many  cases  of  general  paralysis 
there  was  usually  a  history  of  venereal 
infection,  particularly  in  those  cases  of 
the  tabetic  type  in  which  the  dementia 
in  the  early  stage  was  very  slight. 
Lewis,  of  Claybury  Asylum,  investigated 
this  point,  and  found  that  out  of  a  total 
number  of  200  males  suffering  from  all 
forms  of  mental  disease  admitted  to 
Claybury  in  1897,  70  had  suffered  from 
venereal  infection  (including  both  soft 
and  hard  sores).  Of  these  200  cases  24 
were  general  paralytics,  and  in  10  of 
them  there  were  certain  evidences  of  in- 
fection, doubtful  evidence  in  3,  and  no 
evidence  in  5.  Alcoholism  was  relatively 
infrequent  as  a  cause.  In  10  cases  of 
juvenile  general  paralysis  which  Mott 
saw  there  were  undoubted  signs  of  con- 
genital syphilis  (Hutchinson's  teeth, 
linear  cicatrices,  or  interstitial  keratitis) 
in  no  less  than  8.  Again,  he  found  that 
atheroma  of  the  aorta  was  comparatively 
frequent  in  general  paralysis.  Of  8G 
males  dying  under  forty-six  years  of  age, 


INSANITY.    GENERAL  PARESIS.    PATHOLOGICAL  ANATOMY. 


97 


24  had  atheroma  of  the  aorta;  60  of 
these  cases  were  general  paralytics,  of 
whom  22  had  atheroma,  or  1  in  3, 
whereas  the  proportion  was  1  in  13  for 
the  other  cases.  Of  53  females  dying 
under  forty-six,  18  had  atheroma;  18  of 
the  cases  were  general  paralytics,  and  of 
these  10  had  atheroma,  or  more  than 
half.  It  must  be  remembered  that  emi- 
nent authorities  regard  syphilis  as  the 
most  important  cause  of  atheroma  of  the 
aorta.  Mott  (Transactions  of  Asylums 
Committee  of  London  County  Council, 
'98). 

General  paresis  is  increasing  in  fre- 
quency, males  being  still  more  often 
affected  than  females.  The  disease  ap- 
pears to  be  more  common  in  married 
men;  thus,  of  89  male  patients,  64  were 
married,  17  single,  6  widowed,  and  2 
divorced.  The  disease  apparently  occurs 
almost  exclusively  among  married 
women.  Steinach  (Med.  Record,  Dec.  17, 
'98). 

It  is  more  frequent  in  cities  than  in 
country-districts.  Men  are  attacked  from 
three  to  five  times  as  often  as  women. 
The  latter  appear  to  be  becoming  more 
subject  to  the  disease,  as  a  few  years  ago 
the  proportion  in  the  two  sexes  was  stated 
as  one  to  seven.  Clergymen  are  almost 
exempt,  while  actors  and  "men  about 
town"  are  the  most  frequent  victims. 

Pathological  Anatomy. — In  general 
paresis  we  have  a  psychosis  based  upon 
recognizable  structural  alterations  in  the 
brain.  These  alterations  are  so  dissemi- 
nated that  the  entire  brain  undergoes  a 
gradual  loss  of  functioning  power  as  a 
whole.  The  structural  changes  in  the 
brain  are  found  everywhere.  The  vas- 
cular sheaths  are  filled  with  white  and 
red  blood-corpuscles,  the  vascular  walls 
thickened,  and  the  calibre  of  the  vessels 
diminished.  In  the  substance  of  the 
brain  there  is  an  increase  of  the  connect- 
ive-tissue elements  which,  we  have  reason 
to  believe,  produce  atrophy  of  the  brain- 
cells  by  pressure.  There  is  also  fre- 
quently   close    adhesion    between  the 


arachno-pia  and  the  surface  of  the  brain. 
There  is  pretty  constantly  a  disappear- 
ance of  medullary  nerve-fibres.  At  times 
there  are  minute  haemorrhages  into  the 
substance  of  the  brain. 

The  arachno-pia  is  generally  cloudy 
and  thickened.  The  convolutions  are 
diminished  in  volume  and  the  fissures 
wider  than  normal.  The  cortical  sub- 
stance is  decreased.  The  average  dim- 
inution in  weight  of  the  brain  amounts 
to  100  to  200  grammes  (3  to  6  ounces). 

Arachnoid  and  pia  mater  examined  in 
a  series  of  patients  with  general  paraly- 
sis, pellagra,  acute  delirium,  and  other 
psychoses,  particularly  in  the  region  of 
the  central  convolutions,  where  the  me- 
ninges in  general  are  first  subject  to  alter- 
ations. In  general  paralysis  the  well- 
known  vascular  changes  found;  they 
were  even  noticed  at  the  beginning  of 
the  disease,  before  there  was  any  trace 
of  sclerosis  or  atrophy  of  the  cerebral 
substance.  Chronic  hypersemia  of  the 
encephalon  and  the  consecutive  changes 
considered  as  primary  anatomo-patho- 
logical  symptoms  of  paralytic  insanity. 
In  the  pellagrous  lunatic  the  pia  mater 
presents  diffuse  opaque  alterations,  a 
slight  augmentation  of  the  connective- 
tissue  elements,  and  occasionally  an  in- 
filtration of  leucocytes,  collected  around 
the  vessels  or  isolated  in  the  meninges. 
In  the  other  forms  of  insanity  a  slight 
thickening  of  the  pia  mater  was  usually 
noticed;  the  tortuous  vessels  had  rigid 
walls,  as  in  the  case  of  very  old  people 
or  in  those  dying  of  marasmus.  The 
thickening  of  the  pia  mater  usually  be- 
gan at  the  level  of  the  central  convolu- 
tions. Francesco  del  Greco  ("Revista 
Sperimentale  di  Freniatria  e  di  Med. 
Legale  in  Relazione  con  l'Antropologia 
e  le  Scienze  Giuridiche  e  Sociali,"  Reggio- 
Emilia,  '93). 

There  is  a  widely  -  pervading  cell- 
degeneration  of  a  granular,  probably 
fatty  type;  overgrowth  of  the  connect- 
ive-tissue structure  within  the  cerebral 
substance,  and  a  diffuse,  inflammatory 
change  around  the  sheaths  of  the  blood- 


98    INSANITY.    GENERAL  PARESIS.    PATHOLOGICAL  ANATOMY.  PROGNOSIS. 


vessels,  with  slighter  alterations  in  the 
sheaths  themselves.  It  is  regarded  as 
very  probable  that  the  beginning  of  the 
disease  is  to  be  found  in  some  alteration 
of  the  blood-supply,  followed  by  a  peri- 
arterial lymphoid  growth,  disturbance  of 
the  lymph-currents,  consequent  malnu- 
trition of  the  nerve-structures.  The 
skull  is  at  times  markedly  thickened.  In 
the  medulla  oblongata  and  the  spinal 
cord  structural  alterations  similar  to 
those  in  the  brain  are  found. 

"Pathologists  are  not  yet  agreed 
whether  the  essential  morbid  condition 
in  general  paresis  is  inflammatory  or  de- 
generative; whether  the  changes  occur 
first  in  the  nerve-elements,  the  stroma,  or 
the  lymph-  and  blood-  vascular  systems. 
Berkley,  one  of  the  most  recent  observers, 
found  degenerative  changes,  and  then, 
when  the  nerve-elements  begin  to 
atrophy  and  disorganize,  an  overgrowth 
of  the  spider-cells,  with  other  fixed  cell- 
proliferation  among  the  degenerating 
tissues;  then  follow  the  serous  and 
sanguineous  apoplexies  and  other  inci- 
dental symptoms  occasionally  found." 

Whether  general  paralysis  is  a  disease 
svi  generis  or  not,  it  is  certain  that  the 
pathological  appearances  point  to  irrita- 
tive (probably  inflammatory)  processes 
in  the  upper  layers  of  the  convolutions 
in  the  earlier  stages,  and  to  pressure 
signs  from  the  presence  of  fluid  in  the 
later.  T.  Claye  Shaw  (Brit.  Med.  Jour., 
Nov.  16,  '89). 

The  whole  process  of  paresis  starts  in 
the  vessels,  and  from  these  inflammatory 
changes  take  place  in  the  neuroglia, 
which  leads  to  destruction  of  nerve- 
fibres  and  changes  in  the  ganglion-cells. 
General  paralysis  defined  as  an  intersti- 
tial diffuse  encephalitis.  Mendel  (Neurol. 
Centralb.,  Sept.  1,  '90). 

Attempts  made  to  solve  the  much-dis- 
cussed question,  whether  the  degenera- 
tion of  nerves  in  the  progressive  paraly- 
sis of  the  insane  is  dependent  upon  a 
primary  degeneration  of  the  vessels,  by 
examining,  from  the  same  parts  of  the 


brain  of  paralytics,  the  capillaries  for 
their  condition  and  sections  for  degener- 
ation of  fibres.  The  results  were,  that  in 
every  spot  where  degeneration  of  capil- 
laries were  found  degeneration  of  fibres 
could  also  be  ascertained.  Seven  brains 
were  examined,  and  it  was  found  that 
the  capillaries  in  the  frontal  convolutions 
were  always  degenerated.  In  the  cere- 
bellar cortex  they  were  degenerated  4 
times  in  5  cases.  In  the  occipital  lobes 
the  capillaries  in  7  cases  were  healthy 
thrice,  and  those  of  the  central  convolu- 
tions, although  only  examined  twice  in 
either  case,  were  found  diseased.  The 
cortex  of  the  temporal  lobe  showed 
healthy  capillaries  once,  diseased  ones 
twice;  that  of  the  parietal  lobe,  diseased 
ones  once  and  healthy  ones  twice.  Paul 
Kronthal  (Neurol.  Centralb.,  Nov.  15, 
'00). 

"Wasting  of  the  fibres  with  axis-cylin- 
ders in  the  gray  substance  of  general 
paralytics  (confirming  the  previous  ob- 
servations of  Tuczet).  Delicate  fibres  in 
middle  layer  of  gray  matter  first  to  dis- 
appear. A.  Meyer  (Allgemeine  Zeitsch. 
f.  Psychiatrie,  etc.,  B.  51,  H.  4,  '05). 

It  is  probable  that  these  primary 
nutritional  disturbances  are  due  to  toxic 
influences. 

In  the  depressive  delirium  which  often 
precedes  general  paralysis,  the  sum  of 
the  waste-products  eliminated  in  the 
urine  descends  below  the  physiological 
proportion.  In  the  anxious  delirium  one 
observes,  on  the  contrary,  an  increased 
amount  of  solids  in  the  urine,  in  spite 
of  the  insufficient  nutrition  of  the  pa- 
tients. In  the  last  period,  but  not  in 
the  beginning,  the  carbonate  of  am- 
monium is  found  in  the  urine.  Laillier 
(Le  Bull.  Med..  Aug.  15.  '00). 

Prognosis. — The  general  experience  is 
that  general  paresis  is  incurable.  The 
prognosis  is,  therefore,  unqualifiedly 
bad.  AVhile  the  progress  of  the  disease 
can  be  interrupted  by  appropriate  man- 
agement, no  method  of  treatment  is 
known  by  which  it  can  be  permanently 
cured. 


INSANITY.    GENERAL  PARESIS.    TREATMENT.  99 


Apparent  recovery  from  general  paresis 
after  a  residence  in  the  asylum  of  six 
and  one-half  years.  At  the  present  time, 
nineteen  years  after  the  beginning  of  the 
disease,  the  patient  is  engaged  in  prac- 
tice as  a  physician.  It  is  admitted  that 
there  may  be  some  traces  of  mental 
weakness  remaining.  Wendt  (Schmidt's 
Jahrbiicher,  July,  589). 

Acute  confusional  insanity  is  the  only 
mental  disease  besides  general  paralysis 
which  may  cause  death.  The  prognosis 
is  worse  than  in  mania  or  melancholia. 
The  more  complicated  and  changing  the 
form,  the  worse  the  prognosis.  J.  Seglas 
(Archives  Gen.  de  Med.,  May,  June,  '94). 

Treatment. — Obviously  not  much  can 
be  said  about  the  treatment  of  a  disease 
which,  according  to  all  observations,  uni- 
formly tends  to  a  fatal  ending.  It  is 
possible  that  an  early  recognition  of  the 
disease  may  lead  to  measures  to  arrest 
its  progress.  It  must  be  confessed  that 
at  present  our  notions  of  such  measures 
are  extremely  vague. 

Complete  rest  from  business  and  re- 
moval from  all  sources  of  irritation  is 
the  first  object  to  be  striven  for.  Dissipa- 
tion, intemperance  and  venereal  excesses 
must  be  abandoned.  Eemoval  to  a  prop- 
erly managed  institution  as  early  as 
practicable  is,  therefore,  to  be  urged. 
When  the  patient  is  at  liberty  and  in  con- 
trol of  money  or  possessed  of  credit,  his 
expansive  delusions  will  often  lead  him 
to  the  commission  of  acts  which,  while 
not  dangerous,  may  be  decidedly  embar- 
rassing to  himself  or  others. 

Antisyphilitic  treatment  may  be  of 
benefit  even  in  those  cases  where  there  is 
no  evident  syphilitic  taint.  .Mercury  and 
the  iodides,  the  latter  in  large  doses,  may 
cause  arrest  of  the  connective-tissue  pro- 
liferation, and  the  absorption  of  the  new 
formation  in  the  brain  and  spinal  cord. 
From  V2  to  1  ounce  of  iodide  should  be 
given  daily. 

To  combat  the  sleeplessness,  chloral, 


bromides,  sulphonal,  and  paraldehyde  are 
indicated.  In  some  cases,  however,  even 
excessive  doses  of  these  drugs  fail  to  pro- 
duce their  beneficial  effects.  Opium 
may  be  cautiously  tried,  and  will  some- 
times be  effectual. 

Marked  success  in  checking  the  con- 
vulsive seizures  of  general  paralysis  by 
hypodermic  injections  of  ergotinine,  1/m 
grain  in  solution.  One  or  two  injections, 
are  sufficient  to  check  the  convulsions. 
Christian  (La  Trib.  Med.,  Dec.  18,  '89), 

In  general  paralysis  treatment  must 
be  guided  not  by  the  unfavorable  prog- 
nosis, but  by  a  conscientious  endeavor  to 
rescue  the  case.  Many  neurasthenics 
carefully  treated  are  but  general  paretics 
in  the  earliest  stages,  saved  before  the 
fatal  disease  has  a  fixed  hold.  In  cases 
of  suspected  paresis,  the  continuous  ice- 
cap, ergot,  and,  in  maniacal  cases,  injec- 
tions of  ergotine,  the  wet  pack,  sodium 
bromide,  and,  in  proper  cases,  local  blood- 
letting recommended.  The  iodides  should 
be  persistently  tried,  even  in  cases  where 
a  syphilitic  history  is  not  clear.  Mey- 
nert  (Zeitsch.  f.  Therapie,  Aug.  1,  '90). 

Primarily,  the  patient  suffering  from 
paresis  must  be  removed  from  his  usual 
field  of  activity  and  strict  quiet  enjoined. 
Abundant,  but  easily-digested,  food  is  to 
be  prescribed.  Iodide  of  potassium  or 
sodium  will  be  found  useful,  and,  in  cer- 
tain cases,  ergot.  If  a  specific  history  is 
obtained,  active  antisyphilitic  treatment 
is  to  be  pursued. 

For  those  cases  that  unfortunately 
get  beyond  the  first  stage  the  treatment 
is  of  necessity  adapted  to  the  symptoms. 
Krafft-Ebing  (Wiener  med.  Presse,  Nov. 
17,  '90). 

Literature  of  '96-'97-'98. 

The  treatment  of  general  paralysis,  as 
in  the  treatment  of  all  mental  diseases, 
is  preventive  and  moral,  as  well  as 
medicinal. 

Preventive:  The  avoidance  of  mar- 
riage where  a  history  of  insanity  is 
marked,  the  early  recognition  of  the  in- 
cipient  stages  of  the  disease,  and  the 


INSANITY.    GENERAL  PARESIS.  CATATONIA. 


avoidance  of  exciting  causes,  such  as 
mental  strain  and  excesses. 

Moral :  When  the  disease  is  recognized 
removal  from  home  surroundings  is  of 
great  importance,  and  a  quiet  out-door 
occupation  the  best  suited  to  the  bodily 
and  mental  health. 

Medicinal:  Bromides  for  excitement, 
and  bromide  combined  with  chloral  if 
there  is  insomnia.  In  administering 
sedatives  they  should  be  combined  with 
laxatives,  and  the  combination  of  digi- 
talis with  bromides  is  most  useful  in 
relieving  arterial  pressure.  Fletcher 
Beach  (Clin.  Jour.,  Apr.  6,  '98). 

Literature  of  '96-'S7-'98. 

Encouraging  results  obtained  in  the 
treatment  of  paretic  dementia  by  cold 
wet  packs,  always  accompanied  by  cold 
to  the  head  in  the  form  of  an  ice-bag  or 
wet  towel.  The  duration  of  the  pack 
is  from  one  to  three  hours.  The  pack 
is  followed  by  massage  and  sometimes 
by  a  brief  douche.  This  treatment  need 
not  interfere  with  special  treatment, 
such  as  iodide  or  mercurial  inunctions. 

The  details  of  a  cold  or  wet  pack,  as 
used  in  this  treatment,  are  as  follows: 
As  many  blankets  are  used  as  are  con- 
sidered necessary  to  produce  a  good  re- 
action in  the  patient,  placing  one  blanket 
above  another  smoothly  spread  out  upon 
the  bed;  over  all  is  placed  a  linen  sheet 
wet  in  cold  water  and  the  patient  is 
laid  on  that. 

In  wrapping  the  sheet  about  him  care 
should  be  taken  to  separate  adjacent 
parts,  as  arms  and  legs,  from  the  body 
by  folds  of  the  sheet ;  then  he  is  wrapped 
in  the  blankets,  tucking  closely  fold  by 
fold.  The  patient's  head  should  be  wet 
before  he  lies  in  the  pack,  and  after  he 
is  comfortably  placed  in  it  a  wet  towel 
should  be  wrapped  about  his  head  unless 
an  ice-cap  is  deemed  better.  If  patient  is 
very  feeble  and  temperature  of  the  sur- 
face subnormal  more  blankets  will  be 
required,  or  perhaps  hot  bottles  at  feet. 
Massage  is  usually  given  one-half  hour 
after  pack.  In  eases  of  active  excitement 
the  patient  may  be  taken  from  the  pack, 
rubbed  or  douched,  and  put  directly 
back.  If  pyrexia  is  present  it  should  he 
relieved  by  cool   baths  or  short  packs. 


with  light  covering,  before  the  pack, 
above  detailed,  is  given,  otherwise  the 
pyrexia  is  aggravated.  Temperature 
should  be  taken  twice  day,  and  rise 
promptly  met  by  ice  to  the  head.  Bowels 
should  be  carefully  attended  to  to  avoid 
autointoxication.  Codding  (Brit.  Med. 
Jour.,  Nov.  13,  '97). 

Great  care  is  necessary  in  feeding  ad- 
vanced cases  to  prevent  bolting  of  large 
morsels  of  food,  and  consequent  asphyxia 
from  entrance  of  food  into,  or  compres- 
sion of,  the  air-passages.  Attendants 
should  be  instructed  how  to  remove 
masses  of  food  from  the  oesophagus. 

Literature  of  '96-'97-'98. 

In  the  treatment  of  choking  among 
the  insane  manipulating  windpipe  up- 
ward from  the  outside  will  force  food 
up  into  the  throat  so  that  it  can  be 
reached  by  the  finger.  R.  M.  Phelps 
(Jour,  of  Nervous  and  Mental  Disease, 
Mar.,  '96). 

In  the  paralytic  attacks  attention  must 
be  paid  to  regularly  emptying  the  blad- 
der and  rectum. 

Cleanliness  and  frequent  changes  of 
position  in  those  patients  who  have  be- 
come bedfast  from  the  advance  of  para- 
lytic symptoms  will  tend  to  avert  bed- 
sores. When  these  occur,  the  recognized 
I  surgical  measures — namely:  cleanliness, 
bathing  with  dilute  alcohol,  and  removal 
of  pressure — are  indicated. 

Finally,  all  measures  tending  to  make 
the  patient  more  comfortable,  and  less 
objectionable  to  his  surroundings  should 
be  employed. 

Catatonia. 

Definition. — Catatonia  is  a  form  of  in- 
sanity characterized  by  depression,  ex- 
altation, stupor,  confusion,  and  de- 
mentia, usually  occurring  in  regular 
cyclical  sequence.  There  is  also  a  spastic 
condition  of  the  muscles  and  a  tendency 
I  to  rhythmical  movements. 


INSANITY.  CATATONIA. 


SYMPTOMS.  CAUSATION. 


101 


Symptoms  and  Course. — There  is  noth- 
ing peculiar  about  the  prodromic,  or 
primary,  melancholic  stage.  There  are 
the  usual  symptoms  of  mental  and  phys- 
ical depression.  Self-accusation  and  de- 
lusions of  negation  are  not  infrequent. 
Attempts  at  suicide  are  occasionally 
made.  Eefusal  of  food  is  frequent,  but 
not  usually  persistent.  Forcible  feeding 
generally  soon  overcomes  the  reluctance 
to  eat.  On  the  whole,  the  melancholia 
does  not  appear  to  be  so  deep  as  in  the 
ordinary  cases  of  melancholia.  It  has  a 
closer  resemblance  to  the  depressive 
phases  of  certain  cases  of  general  paresis. 

In  the  maniacal  stage  there  is  restless- 
ness with  exaltation,  varying  with  de- 
pression, delusions  of  grandeur,  or  "fits  of 
rage,  culminating  in  attacks  upon  by- 
standers or  in  destructive  tendencies. 

Mutism,  or  dumb  stupor,  is  usually 
present  as  a  stage  in  the  course  of  the 
disease.  It  may  persist  for  long  periods, 
or  may  be  transitory.  There  may  be  ab- 
solute mutism  or  simply  a  refusal  to 
answer  questions.  The  patient  sits  or 
stands  in .  one  position,  with  head  and 
eyes  down,  and  apparently  taking  notice 
of  nothing  passing  around  him.  Care- 
ful observation  will  show,  however,  that 
he  often  gives  quick  and  watchful  glances 
about  and  that  he  is  not  so  deeply  sunk 
in  stupor  as  he  appears  to  be.  At  times 
the  patients  mutter  to  themselves  in  a 
low  tone,  suffering  nothing  in  their  vi- 
cinity to  distract  them. 

There  is  a  generalized  tension  of  the 
muscular  system,  in  consequence  of 
which  the  patient  resists  any  change  of 
position  except  such  as  he  assumes  volun- 
tarily, or  in  which  he  has  been  placed. 
Thus,  cataleptic  states  are  not  infrequent, 
although  not  so  common  as  in  hysterical 
conditions.  The  resistance  to  movement 
is  probably  always  due  to  delusions  of 
anxiety  or  fear,  and  is  not  uncommon  in 


other  mental  disturbances,  especially  in 
melancholia  and  paranoia. 

Among  the  somatic  symptoms  are 
othematoma,  often  anaesthesia,  localized 
cedemas  and  other  disturbances  of  nutri- 
tion. Loss  of  control  over  the  sphincters 
is  usually  present.  According  to  Kahl- 
banm,  pulmonary  phthisis  is  nearly  al- 
ways associated  with  the  later  stages. 

Pathognomonic,  in  addition  to  some 
or  all  of  the  symptoms  above  mentioned, 
is  a  peculiar  aberration  of  speech  termed 
by  Kahlbaum  "verbigeration,"  and  a 
rhythmical  or  stereotypic  movement  of 
certain  groups  of  muscles.  A  spastic 
pouting  or  "Schnauzkrampf"  is  described 
as  especially  frequent.  Other  move- 
ments are  the  constant  twisting,  fraying, 
or  buttoning  and  unbuttoning  of  the 
clothes,  or  the  patient  walks  in  definite 
limited  lines  or  areas,  not  diverging  from 
his  regular  path. 

Verbigeration  consists  in  the  rhyth- 
mical reproduction  of  sounds,  words,  or 
sentences,  often  without  logical  connec- 
tion, which  are  repeated  in  a  declamatory 
or  pathetic  style.  This  verbal  repetition 
is  easily  differentiated  from  the  jabbering 
talkativeness  or  senseless  rhyming  mania 
of  acute  confusional  insanity,  or  the 
drivel  of  advanced  dementia. 

In  advanced  cases  consecutive  de- 
mentia comes  on,  during  which  the 
stereotypic  movements,  verbigeration, 
and  cataleptoid  states  may  persist  in  a 
more  or  less  modified  form. 

Causation. — While  direct  insane  an- 
cestry does  not  seem  especially  influ- 
ential in  the  causation  of  catatonia,  a 
neuropathic  constitution,  hereditary  or 
acquired,  is  a  usual  precedent  condition. 
Among  other  causes,  masturbation  is 
mentioned  by  authors  as  a  frequent  fac- 
tor. While  not  denying  the  influence  of 
this  practice,  the  writer  is  not  inclined  to 


102 


INSANITY.    CONSECUTIVE  DEMENTIA.  SYMPTOMS. 


attribute  to  it  much  weight  in  the  eti- 
ology of  the  affection. 

Diagnosis. —  Stereotypic  movements, 
muscular  tension,  and  stupor  are  not  in- 
frequent in  other  mental  disorders,  espe- 
cially in  so-called  acute  dementia,  para- 
noia, general  paresis,  acute  hallucinatory 
delirium,  grave  hysterical  conditions, 
and  the  insanities  of  pregnancy,  the 
puerperal  period,  and  of  lactation.  For 
a  time  these  symptoms  may  simulate 
catatonia,  but  prolonged  observation 
will  show  that  they  are  merely  incidents 
in  the  development  of  the  particular 
psychosis  in  question,  which  is  easily 
recognized  in  its  further  course.  Most 
of  the  cases  reported  by  American  writers 
as  catatonia  are  probably  of  this  nature. 

Prognosis. — This  is  unfavorable.  Re- 
covery rarely  occurs.  Most  of  the  cases 
die  of  intercurrent  phthisis. 

Pathology. — This  has  not  been  suffi- 
ciently studied.  The  macroscopical  ap- 
pearances in  the  brain  resemble  those  of 
general  paresis. 

Treatment. — This  is  essentially  symp- 
tomatic. 

Consecutive  Dementia. 

Definition. — Consecutive  dementia  is  a 
state  of  permanent  and  incurable  weak- 
mindedness  following  an  acute  psychosis. 

Symptoms  and  Course. — In  one  hun- 
dred cases  of  acute  mania  or  melancholia, 
from  50  to  75  per  cent,  will,  under  ap- 
propriate treatment,  end  in  mental  res- 
toration; 10  to  12  per  cent,  will  die  of 
exhaustion  or  intercurrent  somatic  dis- 
eases; and  the  remainder  will  run  into 
chronic  mania  or  melancholia  or  into  de- 
mentia. By  11  lis  term  is  meant  an  alter- 
ation in  the  mental  functions  character- 
ized primarily  by  enfeeblement  of  the 
psychical  processes.  The  subject  may 
recover  sufficiently  from  the  acute  psy- 
chosis to  properly  perform  mechanical 
labor  of  various  sorts,  particularly  if  he 


is  prompted  by  some  one,  but  consecu- 
tive thought,  especially  upon  a  complex 
subject,  is  impossible.  Such  persons  are 
sometimes  spoken  of  as  having  recovered 
with  defective  action  of  the  brain,  and 
many  of  the  cases  of  mania  discharged 
from  hospitals  as  recovered  are  examples 
of  such  partial  destruction  of  brain- 
power. He  can  continue  doing  his  usual 
work,  especially  if  it  is  mechanical  and 
does  not  involve  complex  mental  proc- 
esses; but  he  is  easily  confused,  is  often 
irritable,  may  retain  delusions  or  have 
hallucinations,  and  is  altered  in  disposi- 
tion in  various  ways.  His  friends  will 
often  remark  that  he  is  not  the  same 
since  as  before  his  illness,  but  it  is  often 
not  easy  to  define  exactly  in  what  this 
alteration  consists.  In  a  more  pro- 
nounced form  of  dementia  there  is  great 
confusion  of  thought.  Consecutive  ac- 
tion as  well  as  consecutive  thinking  be- 
comes impossible.  The  dement  of  this 
stage  may  wheel  a  barrow,  dig  a  trench, 
shovel  sand,  break  stone,  or  chop  wood 
with  a  good  deal  of  energy,  but  every 
little  while  he  stops,  looks  vacantly 
around,  until  his  attendant  calls  to  him, 
or  until  the  repetition  of  some  associative 
sight  or  sound  calls  up  the  remembrance 
of  what  he  is  doing,  and  of  the  necessity 
for  "moving  on."  It  is  often  extremely 
interesting  to  watch  these  mental  para- 
lytics at  their  occupation,  and  to  note  the 
breaks  in  the  continuity  of  their  mental 
processes. 

Among  the  relics  in  all  hospitals  and 
asylums  for  the  insane  are  many  in  whom 
the  fire  of  maniacal  exaltation  has  burned 
out.  They  lack  all  consecutive  mental 
activity.  To  the  loss  of  intellectual 
power  and  volition  is  added  the  failure 
of  motor  power.  The  subject  has  become 
a  paralytic  and  sits  or  lies  in  bed.  or  on 
the  floor,  staring  vacantly,  taking  no 
notice  of  his  surrounding?,  passing  urine 


INSANITY.    SENILE  DEMENTIA.  SYMPTOMS. 


103 


and  faeces  unconsciously,  eating  every- 
thing placed  before  him,  or  put  into  his 
mouth,  and  sometimes  picking  up  and 
swallowing  the  most  disgusting  things. 

Speech  is  often  defective  in  consecu- 
tive dementia.  It  is  slurring  or  lisping, 
and  sometimes  stammering,  or  syllables 
are  cut  off  or  dropped  out  of  words.  This 
may  be  due  to  structural  change  in  the 
speech-centre  or  defect  in  the  conduction 
of  efferent  impulses.  At  times  there  is 
mnemonic  aphasia. 

Diagnosis. — Consecutive  dementia  re- 
sembles in  many  respects  idiocy  and  im- 
becility, from  which  it  is  easily  differen- 
tiated by  the  history.  General  paresis 
rarely  offers  any  difficulty,  as  the  active 
delusions  in  this  disease  differentiate  it 
readily  from  consecutive  dementia. 

Prognosis. — Consecutive  dementia,  be- 
ing due  to  structural  alteration  in  brain- 
tissue,  is,  in  the  present  state  of  knowl- 
edge, incurable.  It  is  often  not  actively 
progressive,  and  the  dement  may  live  in 
good  physical  health  and  weakened 
mental  power  for  many  years.  In  insti- 
tutions for  the  insane  tuberculosis  finds 
most  of  its  victims  among  the  subjects  of 
dementia. 

Treatment. — This  is  purely  symptom- 
atic. Systematic  employment  and  care- 
ful attention  to  nourishment  and  sleep 
will  make  most  dements  comfortable. 

Senile  Dementia. 

Definition.  —  Senile  dementia  is  a 
chronic,  progressive  weak-mindedness 
due  to  structural  alteration  in  the  brain 
occurring  in  advanced  life. 

Symptoms  and  Course. — As  the  phys- 
ical powers  decay  with  advancing  years, 
the  intellectual  functions  also  become  im- 
perfect. There  is  in  some  cases  a  gradual 
alteration  of  the  character  of  the  person. 

Memory  of  recent  occurrences  is 
usually  impaired,  while  the  recollection 
of  past  events  is  sometimes  very  detailed, 


if  not  exact.  Old  stories  are  told  and 
retold  without  remembering  that  they 
were  told  before.  The  subject  becomes 
suspicious  of  his  relatives  and  friends,  is 
easily  excited  and  irritated,  misplaces 
articles  and,  forgetting  where  they  were 
placed,  accuses  others  of  stealing  them. 

Among  the  prominent  symptoms  are 
increased  sexual  desire,  with  diminution 
of  power  to  perform  the  sexual  act.  The 
patient  not  rarely  makes  unseemly  ex- 
posure of  his  person,  and,  as  if  conscious 
of  his  sexual  incapacity,  commits  inde- 
cent assaults  upon  young  girls. 

The  senile  dement  is  obstinate  and 
vain.  He  will  not  recognize  the  fact  that 
his  physical  and  mental  powers  are 
waning,  but  insists  that  he  is  as  capable 
of  conducting  his  business  and  other 
affairs  as  when  in  the  prime  of  life. 
Thus,  the  doctor  who  is  the  victim  of 
beginning  senile  dementia  believes  him- 
self more  capable  than  ever  of  attending 
to  his  professional  duties,  and  resents  the 
imputation  that  he  is  getting  too  old  to 
do  his  work  properly.  The  clergyman 
knows  that  he  can  and  does  preach  bet- 
ter sermons  than  ever,  and  attributes  the 
decrease  in  size  of  his  congregation,  if  he 
notices  it  at  all,  to  the  influence  of  envi- 
ous opponents  who  are  endeavoring  to 
lead  his  people  away  for  selfish  reasons. 
The  story  of  the  Archbishop  of  G-ranada 
in  "Gil  Bias"  is  an  exquisite  example  of 
senile  dementia. 

Among  the  more  striking  physical 
symptoms  are  those  associated  with 
structural  alterations  in  the  central  nerv- 
ous system.  There  is  usually  a  halting 
or  lisping  speech;  the  gait  becomes 
slovenly  or  shuffling;  there  is  loss  of  con- 
trol over  the  sphincters,  the  urine  and 
alvine  evacuations  passing  into  the 
clothing  and  bed  unconsciously.  There 
are  also  occasional  slight  paralytic 
strokes,  sometimes  with  temporary  loss 


10-i 


INSANITY.    SENILE  DEMENTIA.    EPILEPTIC  DEMENTIA. 


of  consciousness.  These  are,  however, 
generally  quickly  recovered  from. 

The  sleep  is  usually  disturbed,  al- 
though in  the  later  stages  the  opposite 
condition,  a  constant  desire  to  sleep,  may 
be  present. 

There  is  often  a  great  tendency  to 
stray  away,  requiring  the  patient  to  be 
constantly  watched. 

Senile  dementia  is  rare  before  the 
sixtieth  year.  Its  course  is  usually  slow, 
running  over  several  years.  Striking  im- 
provement is  sometimes  observed,  though 
it  is  rarely  permanent.  In  the  later 
stages  when  the  patients  are  confined  to 
bed,  there  are  often  large  bed-sores, 
which  increase  the  difficulty  of  treat- 
ment. 

Diagnosis. — The  history  of  the  case  is 
usually  sufficient  to  prevent  mistake. 
Some  tardy  cases  of  general  paresis  may 
be  confounded  with  senile  dementia,  but 
a  short  period  of  observation  should  be 
sufficient  to  make  a  definite  diagnosis. 

Literature  of  '96-'97-'98. 

The  causation  of  senile  insanities  con- 
sidered as  those  so  remote  as  to  have 
been  beyond  control,  those  in  action  in 
earlier  periods  of  life,  and  those  in  action 
when  senility  is  impending.  Under  the 
second  class,  which  are  within  the  range 
of  medical  direction,  are  principally  the 
causes  of  vascular  change  and  premature 
senility  of  the  arteries.  These  are 
chronic  alcoholism,  syphilis,  gout,  rheu- 
matism, venereal  excess,  great  and  pro- 
longed physical  strain,  intense  and  long- 
continued  mental  application,  with 
anxiety  of  worry  and  lack  of  self-control. 
Ralph  Lyman  Parsons  (Med.  Rec,  Oct. 
10,  '96). 

Reports  on  192  autopsies  in  two  years. 
In  a  large  number  of  senile  dements  the 
fundamental  cause  consisted  in  atherom- 
atous degeneration  of  the  cerebral  blood- 
vessels and  in  the  frequently  resulting 
atrophy  of  the  brain.  These  anatomical 
changes   stand  as  the   basis  of  senile 


dementia.  Adolf  Meyer  (Path.  Report, 
111.  East.  Hosp.  for  the  Insane,  '96). 

1.  The  rate  of  loss  in  brain- weight  in 
chronic  insanity  is  dependent  upon  the 
duration  of  the  dementia. 

2.  The  onset  of  senility  is  attended 
with  an  increased  loss  in  brain-weight. 

3.  The  pathological  evidence  of  incipi- 
ent dementia  (beginning  loss  of  brain- 
weight)  suggests  that  the  onset  of  chro- 
nicity  occurs  at  an  earlier  period  of  a 
psychosis  than  the  clinical  symptoms 
would  lead  us  to  believe.  W.  L.  Bab- 
cock  (Phila.  Med.  Jour.,  June  18,  '98). 

Prognosis. — This  is  unfavorable.  Ke- 
covery  of  normal  mental  function  never 
takes  place. 

Treatment. — The  treatment  is  symp- 
tomatic. The  patient  needs  constant 
care  to  keep  him  clean,  to  prevent  stray- 
ing off,  and  to  avert  injury  likely  to  re- 
sult from  his  carelessness. 

When  there  is  defective  circulation  a 
mild  stimulant  may  be  useful.  Sleep  is 
best  induced  by  malt  liquors,  paralde- 
hyde, trional,  or  opium.  Chloral  should 
be  avoided  on  account  of  its  depressing 
effects. 

Epileptic  Dementia. 

Definition. — A  form  of  dementia  oc- 
curring in  advanced  stages  of  epilepsy, 
due  to  structural  alterations  in  brain- 
tissue. 

Symptoms  and  Course. — A  large  pro- 
portion of  epileptics  are  attacked  by  a 
secondary  dementia,  which  is  usually 
progressive. 

In  the  early  stages  there  are  frequent 
outbreaks  of  violence,  which  may  be  due 
to  hallucinations  or  delusions.  The 
epileptic  dement  is  often  extremely  dan- 
gerous from  the  sudden  and  unpro- 
voked character  of  the  violent  outbreaks. 
He  is  usually  quarrelsome  with  the  weak 
and  peaceably  inclined,  but  soon  acquires 
a  wholesome  respect  for  those  who  strike 
back.  He  usually  makes  constant  com- 
plaints, often  false,  of  ill-usage  on  the 


»  NO  NEEDLESS  REWRITING  OF  NAMES. 


Simplicity, 

Economy, 

Convenience 


lit 


-A.I^E   ALL   COMBINED  ITST 


The  /Vledical  bulletin 
Visiting  feist 


Arranged  upon  an  Original  and  Convenient  Monthly 
and  Weekly  Plan  for  the  Daily  Recording 
of  Professional  Visits. 


HE  plan  of  this  visiting  list  is  the  very  best  ever 


\  devised  for  the  convenient  use  of  all  physi- 
cians, and  embraces  a  new  feature  in  recording 
daily  visits  not  found  in  any  other  list,  consisting 

Of  STUB  OR  HALF  LEAVES  IN  THE  FORM  OF  IN- 
SERTS, a  glance  at  which  will  suffice  to  show  that  as  the 
first  week's  record  of  visits  is  completed  the  next  week's 
record  may  be  made  by  simply  turning  over  the  stub-leaf, 
w  ithout  the  necessity  of  rewriting  the  patients'  names. 
This  is  done  until  the  month  is  completed,  and  the  phy- 
sician has  kept  his  record  just  as  complete  in  every  de- 
tail of  visit,  CHARGE,  CREDIT,  etc.,  as  he  could  have 
done  had  he  used  any  of  the  old-style  visiting  lists,  and 
has  also  SAVED  himself  three-fourths  of  the  time  and 
labor  formerly  required  in  transferring  names  EVERY 
week.    There  are  no  intricate  rulings;  everything  is  eas- 


 of  


Physician's  Call  Record. 


ily  and  quickly  understood;  not  the  least  amount  of  time 
can  be  lost  in  comprehending  the  plan,  for  it  is  acquired 
at  a  glance.  

THE  THREE  DIFFERENT  STYLES  MADE. 
The  No.  1  Style  of  this  List  provides  ample  space 
for  the  DAILY  record  of  seventy  (70)  different  names 
each  month  for  an  entire  year  (two  full  pages,  thirty- 
five  [35]  names  to  a  page,  being  allowed  to  each  month ), 
so  that  its  size  is  sufficient  for  an  ordinary  practice;  but 
for  physicians  who  prefer  a  List  that  will  accommodate 
a  larger  practice  we  have  made  a  No.  2  Style,  which 
provides  ample  space  for  the  daily  record  of  ONE  HUN- 
DEED  AND  FIVE  (105)  DIFFEREXT  NAMES  each  month 
for  a  year  (three  full  pages  being  allowed  to  each  month) ; 
and  for  physicians  who  may  prefer  a  pocket  .Record* 
Book  of  less  thickness  than  either  of  these  styles  we  ha'  e 
made  a  No.  3  Style,  in  which  "'The  Blanks  for  fche  Re* 
cording  of  Visits  in"  have  been  made  into  removable 
sections.  These  sections  are  very  thin,  and  are  made  up 
so  as  to  answer  in  full  the  demands  of  the  largest  prac- 
tice, each  section  providing  ample  space  for  the  daily 

RECORD  OF  TWO  HUNDRED  ANl?  TEN'  I  "210  )  DIFFER FXT 

names  each  month  for  two  m  rnths;  or  one  hundred  and 
five  (105)  different  names  daily  each  month  for  four 
months;  or  seventy  (70)  different  names  daily  each 
month  for  six  months.  Six  sets  of  these  sections  go  with 
each  copy  of  Xo.  3  Style. 


SPECIAL  FEATURES  NOT  FOUND  IN  ANY 
OTHER  LIST. 

In  this  Xo.  3  Style  the  prixted  matter,  and  such 
matter  as  the  rlaxk  form  for  Addresses  of  PA- 
tiexts,  Obstetric  Record,  Vaccination  Record,  (  ash 
Account,  Birth  and  Death  Records,  etc..  are  fastened 
permanently  in  the  back  of  the  book.  The  addition  of 
one  of  the  removable  sections  does  not  increase  the  thick- 
ness more  than  an  eighth  of  an  inch.  This  brings  the 
book  into  such  a  small  compass  that  no  one  can  object 


to  it  on  account  of  its  thickness,  as  its  bulk  is  very 
MUCH  less  than  that  of  any  visiting  list  ever  published. 
As  soon  as  a  section  is  full  it  is  taken  out.  filed  away, 
and  another  inserted  without  the  least  inconvenience  or 
trouble. 


EXTRA  OR  ADDITIONAL   SECTIONS  FURNISHED  AT 
ANY  TIME.    PRICE,  15  CENTS  EACH,  NET. 

This  Visiting  List  contains  a  calendar  for  the  last  six 
months  of  last  year  and  all  of  this  and  next  years:  Table 
of  Signs  to  be  used  in  Keeping  Accounts;  Table  of  Fees; 
Dr.  Ely's  Obstetrical  Table;  Tables  for  Calculating  the 
Number  of  Doses  in  a  given  B,  etc.  etc.;  for  Converting 
Apothecaries '  Weights  and  measures  into  Grammes :  Met- 
rical Avoirdupois  and  Apothecaries'  Weights;  Number 
of  Drops  in  a  Fluidracm;  Graduated  Doses  for  Children; 
Graduated  Table  for  Administering  Laudanum;  Periods 
of  Eruption  of  the  Teeth;  the  Average  Frequency  of  the 
Pulse  at  Different  Ages  in  Health:  Formula?  and  Doses 
of  Hypodermic  Medication  ;  Use  of  the  Hypodermic 
Syringe;  Formula? and  Doses  of  Medicines  for  Inhalation; 
Fornmke  for  Suppositories  for  the  Rectum;  the  Use  of 
the  Thermometer  in  Disease;  Poisons  and  their  Anti- 
dotes; Treatment  of  Asphyxia;  Anti-emetic  Remedies; 
Nasal  Douches;  Eye-washes,  etc.,  etc. 


THE  MOST  CONVENIENT   TIME-  AND  LABOR- 
SAVING  LIST  ISSUED. 

It  is  EVIDENT  TO  EVEEY  ONE  THAT  THIS  IS.  BEYOND 
QUESTION,  THE  BEST  AND  MOST  CONVENIENT  TIME-  AND 
LABOR-  SAVING  PHYSICIAN  S  POCKET  RECORD-BOOK 
EVER  PUBLISHED.  Physicians  of  many  years'  standing 
and  with  large  practices  pronounce  this  the  Best  List 
they  have  ever  seen.  It  i>  handsomely  bound  in 
fixk.  sTK«)N<f  Leather,  with  flap,  including  a 
pocket  FOR  LOOSE  MEMORANDA,  etc..  and  is  furnished 
with  a  Dixon  lead-pencil  of  excellent  quality  and  finish. 
It  is  compact  and  convenient  for  earn  ing  in  the  pocket. 
Size.  4  x  6j|  inches. 


tm  Three  Styijes. 

lfl  w  NET  PRICES. 

No  1.  Regular  size,  to  accommodate  70 
patients  daily  each  month  for  one 
year  

No.  2.  Large  size,  to  accommodate  105 
patients  daily  each  month  for  one 

1.50 

year,  

No  3.  in  which  the  "Blanks  for  Record- 
ing Visits  in  "  are  in  removable 
sections,  

„  B  —THE  RECORDING  OF  VISITS  IK  THIS  LIST  MAY  BE  COMMENCED 
W.B    Iflt  «  tim£  DURIMG  the  YEAR. 


-     WHAT  IS  SAID  OF  IT. 

bault  Co.,  Minn. 

nT>    xn  2  Medical  brLi>Kii> 

VI8;rs,,^r^ffl'rf« « ,i,era 

X{?"w  H  SiBD,  M.D.,  Camden,  N.J. 

'  "I,  fin.  all  requirements  ami  excee*  my  «pectat..m.  - 
DE  D  SauerhfV'G.  Milwaukee.  v\  ... 

J  C   Jpplegate,  M.D.,  Bn.lgeton,  N.  J. 

possesses  some  ^^^^S^m 
of  rewriting  names  every  week K i  ob JJ*~^  mucJ5  valuable 

^^■Sa^^SK  the  bo^B^ 
caZ  Jnd  Surgical  Journal.  ,     .n  ,  .._ 

-Kvervtbine  nb,ut  it  is  easily  and  quickly  nnderetood. 

Publishers. 

THE  F.  A.  DAVIS  CO.,  Publishers, 

PHILADELPHIA:  1914  and  1916  Ch.rr, ^..t. 
„tw  vdrtc  ■  117  West  Forty-Second  Street. 

SaGO   9  U*.  MUb..  »»  '» ••  st"" 

2  5—99 


INSANITY.    SYPHILITIC  INSANITY 


105 


part  of  others.  Untruthfulness  is  so  fre- 
quent among  epileptic  dements  that  it 
may  be  almost  regarded  as  a  character- 
istic. 

In  advanced  cases  the  failure  of  the 
mental  and  physical  powers  becomes 
very  noticeable.  The  speech  is  affected 
and  control  of  the  sphincters  is  lost. 
Most  patients  die  in  status  epilepticus, 
intercurrent  pneumonia,  or  exhaustion. 

Treatment. — All  epileptic  dements 
should  be  placed  in  appropriate  institu- 
tions on  account  of  the  danger  from  out- 
breaks of  violence.  The  usual  remedies 
for  epilepsy  may  delay  the  progress  of 
the  dementia,  but  no  hope  of  arresting 
it  can  be  entertained. 

Group  V.  Psychoses  due  to  Gross 
Lesiox  in  the  Braix. 

Under  the  term  organic  dementia 
authors  describe  those  forms  of  insanity 
due  to  destruction  of  areas  of  brain- 
tissue  following  syphilitic  deposits,  ab- 
scesses, hemorrhagic  infarctions,  tumors, 
aneurisms,  and  cranial  traumatisms. 

Syphilitic  Insanity. 

Definition. — Insanity  due  to  syphilitic 
new  formation  in  the  brain  or  meninges. 

Symptoms.  —  Severe  and  long-con- 
tinued headache,  more  intense  usually  at 
night,  frequently  precedes  any  psychical 
manifestations.  Attacks  of  unconscious- 
ness, sometimes  convulsions  and  coma, 
are  not  rare.  After  one  of  these  attacks 
there  is  frequently  local  or  general  pa- 
ralysis, which  may  be  transitory  or  per- 
manent. Ptosis  is  a  frequent  symptom. 
Halting  speech  and  actual  aphasia  may 
also  occur. 

Stupor  and  depression  may  alternate 
with  maniacal  outbreaks.  The  memory 
is  often  profoundly  impaired,  the  patient 
forgetting  even  his  own  name,  business, 
and  place  of  residence.  In  many  cases 
the  symptoms  resemble  so  closely  those 


of  general  paresis,  including  delusions  of 
grandeur,  that  a  differential  diagnosis  is 
impossible  during  life.  In  most  cases, 
however,  the  motor  disturbances  are  of  a 
more  distinctly  paralytic  character,  com- 
plete loss  of  power  of  certain  muscular 
groups  being  more  frequent  than  in  gen- 
eral paresis. 

In  advanced  stages  the  dementia  is 
usually  profound. 

Diagnosis. — This  must  depend  largely 
upon  the  history.  The  presence  of  evi- 
dences of  syphilis  in  other  organs;  sud- 
den attacks  of  aphasia,  following  apo- 
plectic or  epileptiform  seizures;  hemi- 
plegia and  ptosis,  with  the  psychical 
symptoms  above  mentioned,  will  permit 
a  probable  diagnosis  to  be  made  in  the 
majority  of  cases.  As  stated,  however,  a 
positive  differentiation  from  general 
paresis  is  often  impossible  during  life. 

Literature  of  ?96-,97-J98. 

Conclusions  based  on  a  study  of  syph- 
ilis in  its  relation  to  insanity  summed 
up  in  the  form  of  a  suggestion  for  a  pro- 
visional scheme  of  classification  as  fol- 
lows:— 

I.  Insanity  of  early  syphilis  (primary 

and  secondary). 

1.  Acute  toxic  insanity  (analogous 
to  delirium  or  mania  a  potu ) . 

2.  Melancholia  with  or  without  de- 
mentia, probably  due  to  cerebral 
anaemia. 

II.  Insanity  of  late  (tertiary)  syphilis. 

1.  Insanity  due  to  syphilitic  disease 
of  the  base  and  vessels. 

2.  Insanity  due  to  syphilitic  disease 
of  the  convexity. 

Most,  if  not  all,  cases  of  cerebral  syph- 
ilis in  which  insanity  has  been  caused 
by  epilepsy  will  fall  under  the  second 
head  (II,  2),  but  should  rather  be  classed 
with  epileptic  insanity,  being  only  in- 
directly due  to  syphilis. 

III.  Metasyphilitic  (parasyphilitis  in- 
sanity. 


X06     INSANITY.    POST- APOPLECTIC.    INSANITY  FROM  CEREBRAL  TUMORS. 


1.  Insanity  of  tabes  (so  far  as  due 
to  other  than  "moral"  causes). 

2.  General  paralysis  of  the  insane. 

This  classification  only  includes  cases 
in  which  there  is  certainly,  or  probably, 
a  gross  anatomical  change  at  the  basis 
of  the  mental  symptoms.  But  it  is  ob- 
vious that  there  are  various  indirect 
ways  in  which  a  disease  like  syphilis 
may  produce  morbid  action  in  unstable 
minds.  Such  are  the  fear  of  contracting 
the  disease;  the  worry,  remorse,  and 
anxiety  produced  by  its  existence;  and 
the  pain  and  insomnia  and  other  sensory 
symptoms  so  common  in  its  course. 
With  this  class  of  cases,  as  being  but  the 
indirect  result  of  the  disease,  and  in  no 
way  peculiar,  no  attempt  has  been  made 
to  deal.  W.  R.  Dawson  (Jour.  Mental 
Science,  Apr.,  '98). 

Pathological  Anatomy. — The  syphi- 
litic neoplasm  may  be  in  the  form  of  a 
diffused  gummatous  meningitis,  endar- 
teritis, or  gummatous  foci  in  the  brain. 
Meningitis  may  also  result  from  gum- 
matous osteitis  of  the  cranial  bones. 

Prognosis. — In  the  early  stages  if  ap- 
propriate treatment  is  promptly  insti- 
tuted the  prognosis  is  not  unfavorable. 
If,  however,  the  morbid  process  has  ad- 
vanced, and  brain-tissue  has  been  de- 
stroyed by  the  neoplastic  infiltration,  or 
by  the  endarteritic  process,  no  hope  of 
restoring  the  normal  condition  can  be 
entertained. 

Treatment. — Mercurial  inunction  and 
potassium  iodide  in  large  doses  should  be  j 
employed  as  soon  as  a  probable  diagnosis 
is  made.  The  iodide  may  be  given  in 
doses  of  Y2  to  1  ounce  daily,  pushing  it 
to  the  limit  of  tolerance.  The  effects  of 
mercury  must  be  watched,  and  care 
taken  to  keep  the  patient's  nutrition  at 
a  proper  standard.  Ferruginous  tonics 
will  generally  be  required. 

In  paralytic  cases  the  development  of 
bed-sores  should  be  carefully  guarded 
against. 


Post-apoplectic  Insanity. 
Definition.  —  Insanity   following  de- 
struction of  an  area  of  brain-tissue,  due 
to  cerebral  haemorrhage  or  embolism. 

Symptoms. — In  addition  to  the  usual 
physical  symptoms  following  gross  brain- 
lesions, — aphasia,  hemiplegia,  etc., — 
there  are  loss  of  memory,  dementia,  and 
occasional  attacks  of  emotional  disturb- 
ance or  outbreaks  of  maniacal  violence. 

Treatment. — This  can  only  be  symp- 
tomatic. Securing  good  nutrition  and 
sleep,  guarding  against  bed-sores,  keep- 
ing the  patient  as  comfortable  as  possible, 
is  all  that  can  reasonably  be  striven  after. 
Mental  restoration  is  not  to  be  expected. 

Insanity  from  Cerebral  Tumors  and 
Abscesses. 

In  many  cases  of  brain-tumor  or  brain- 
abscess  no  psychical  symptoms  are  pres- 
ent. In  others,  however,  there  is  loss  of 
memory,  apathy,  dullness  of  perception, 
occasionally  of  intellectual  perversion. 
Hallucinations  and  delusions  may  be 
present.  When  the  neoplasm  encroaches 
upon  the  visual  sphere,  hallucinations  of 
vision  may  complicate  loss  of  sight.  In 
one  case  of  a  large  abscess  in  the  occipital 
lobe  there  was  almost  entire  loss  of  vision, 
with  delusions  of  personality,  probably 
depending  upon  visual  hallucinations. 
Christian  and  Eaymond  have  reported 
cases  of  hallucinations  of  vision  ap- 
parently depending  upon  intercranial 
growths. 

Treatment. — Obviously  the  only  treat- 
ment that  can  be  considered  is  palliation 
of  the  symptoms  and  surgical  interfer- 
ence. 

Insanity  from  Cranial  Traumatism. 

Insanity  follows  cranial  injuries  much 
more  frequently  than  is  commonly  sup- 
posed. The  delirium  attending  concus- 
|  sion  of  the  brain  or  traumatic  meningitis 
may  be  ignored  here  entirely  as  apper- 
taining entirely  to  surgery.    But  many 


INSANITY  FROM  TRAUMATISM. 


107 


of  the  cases  recovering  from  the  acute 
mental  disturbances  following  shock  and 
inflammation  later  become  permanently 
insane. 

Over  36,000  clinical  histories  examined 
with  the  view  of  determining  whether 
there  is  such  a  form  as  traumatic  in- 
sanity or  whether  the  psychical  disturb- 
ances following  traumatism  only  excep- 
tionally present  characters  of  a  special 
psychosis  in  the  stricter  sense  of  the 
term.  There  were  found  23  females,  6. 
still  living,  and  102  men,  23  of  whom 
were  still  under  treatment.  In  28  cases 
there  was  an  heredity:  in  97,  none.  The 
prevalent  form  of  injuries  was  a  fall  on 
the  head.  In  both  sexes  the  conse- 
quences were  epilepsy,  melancholia,  de- 
mentia, mania,  imbecility,  and  moral  in- 
sanity. The  psychical  phenomena  ap- 
peared in  some  cases  a  few  days  after 
the  injury,  and  in  others  their  first  ap- 
pearance varied  from  a  few  months  to  a 
few  years.  Gonzales  (Archivio  Ital.  per 
le  Mai.  Nervose  e  piti  Partic.  per  le 
Alien.  Mentale,  Milan,  '92). 

It  has  been  pointed  out  by  Sir  J.  Batty 
Tuke  and  others  that  a  condition  closely 
resembling,  if  not  identical  with,  gen- 
eral paresis  follows  injury  to  the  brain. 

[A  case  of  this  sort  is  at  present  under 
my  observation.  The  patient,  a  painter, 
sustained  a  severe  shock  by  falling  from 
a  scaffold  and  striking  upon  his  head. 
Unconsciousness  and  delirium  continu- 
ing for  ten  days  succeeded  the  injury. 
On  recovering  consciousness  there  were 
delusions  of  grandeur,  which  lasted  for 
nearly  a  year,  gradually  becoming  less 
marked.  The  pupils  were  for  a  long 
time  contracted  and  fixed,  not  reacting 
at  all  to  light  and  pain  and  only  very 
slightly  to  accommodation.  After  a 
year  the  expansive  delusions  disappeared 
and  there  remained  a  moderate  state  of 
dementia,  which  appears  stationary. 

Localizing  symptoms  of  focal  disease 
have  never  been  present.  George  H. 
Roue.] 

Treatment. — In  cases  of  fracture  of 
the  skull  the  recognized  surgical  pro- 
cedures are  indicated.     In  contusion, 


opening  of  the  skull  at  a  point  opposite 
to  the  site  of  injury  will  often  show  evi- 
dences of  inflammation  of  the  meninges 
and  contusion  of  the  brain.  It  is  prob- 
able that  trephining  and  drainage  would 
here  sometimes  prevent  the  subsequent 
development  of  insanity. 

Insanity  due  to  injuries  of  head  of 
rather  infrequent  occurrence.  Two  cases 
in  which  cure  followed  trephining.  Cale 
(N.  Y.  Med.  Jour.,  Oct.  12,  '95). 

Case  of  insanity  and  epilepsy  nineteen 
years  after  causative  injury.  Trephining 
followed  by  complete  recovery.  Binet 
and  Rabatel  (Lyon  Med.,  May  12,  '95). 

In  the  secondary  dementias  following 
brain-injuries,  operative  procedures,  un- 
less demanded  by  focal  symptoms,  are 
not  likely  to  be  beneficial. 

Trephining  cannot  as  yet  be  reckoned 
among  methods  of  treatment.  Excision 
of  parts  of  cortex  seems  altogether  un- 
acceptable. Semelaigne  (Annales  Med.- 
psychol.,  May,  '95). 

Group  YI.  Psychoses  due  to  Toxic 
Substances  Circulating  in  the 
Brain. 

In  this  group  are  brought  together  not 
only  those  cases  in  which  the  cause  can 
be  clearly  attributed  to  a  poison  circu- 
lating in  the  blood, — such  as  alcohol, 
lead,  and  drugs  (salicylic  acid,  opium,  co- 
caine),— but  also  those  which  are  be- 
lieved to  be  due  to  autogenetic  or  in- 
fective toxins,  such  as  puerperal  and 
surgical  sepsis,  uraemia,  the  toxins  of  in- 
fluenza, typhoid  fever,  pneumonia,  in- 
solation, etc. 

The  type  of  all  the  different  toxaemic 
psychoses  is  that  described  by  different 
authors  under  the  names  "acute  de- 
lirium," "acute  delirious  mania,"  "de- 
lirium grave,"  "acute  hallucinatory  con- 
fusion" and  numerous  other  synonyms, 
but  which  will  be  here  considered  under 
the  name  siu^ested  by  II.  C.  Wood. 


108  INSANITY.    ACUTE  CONFUSIONAL.    SYMPTOMS.  CAUSATION. 


"Acute  Confusional  Insanity."  The 
general  description  will  indicate  the  type, 
while  variations  will  be  mentioned  under 
the  specific  forms. 

Acute  Confusional  Insanity. 

Definition. — An  acute  form  of  mental 
disturbance,  beginning  suddenly  or  with 
few  prodromes,  characterized  by  inco- 
herence and  confusion  of  thought,  excite- 
ment, or  at  times  stupor,  hallucinations, 
fever,  and  a  tendency  to  exhaustion. 

Symptoms. — Headache  and  insomnia 
may  precede  the  outbreak.  Usually, 
however,  the  only  noticeable  prodromic 
symptom  is  a  state  of  irritability  or 
anxiety.  In  most  cases  the  patients  sud- 
denly become  excited,  talkative,  have 
hallucinations  or  illusions,  which  are 
rarely  of  an  agreeable  character.  They 
may  see  rats,  snakes,  spots  of  blood,  etc. 
The  visual  hallucinations  are  often  like 
those  of  delirium  tremens,  so  graphically 
described  by  Kerr  in  the  first  volume  of 
this  Cyclopedia.  Auditory  hallucina- 
tions may  also  be  present,  but  are  infre- 
quent. The  hallucinations  and  illusions 
are  usually  of  a  changeable  and  fleeting 
character.  Sometimes  there  are  delu- 
sions of  suspicion  and  persecution,  and 
occasionally  delusions  of  grandeur.  The 
patient  soon  becomes  incoherent,  loses 
all  relation  of  time  and  space,  does  not 
recognize  his  surroundings,  and  con- 
founds his  own  and  others'  personality. 
There  may  be  sudden  outbreaks  of  vio- 
lence, which  sometimes  lead  to  homicidal 
acts,  as  in  cases  of  puerperal  and  alcoholic 
insanity.  The  hallucinations  and  illu- 
sions are  sometimes  of  an  erotic  char- 
acter. 

Temporary  lucidity  may  occur,  but  is 
usually  transitory. 

Some  patients  are  excessively  loqua- 
cious, chattering  senselessly  all  the  time, 
making  nonsensical  rhymes,  or  repeating 
a  great  number  of  words  having  a  similar 


sound.  Thus,  a  remark  that  the  patient 
looks  bright  will  lead  to  a  string  of  words 
like:  "bright,  light,  sight,  tight,  fight, 
night,  kite,"  as  if  read  from  a  rhyming 
dictionary.  At  times  the  patient  makes 
new  and  often  bizarre  words.  This  is 
perhaps  a  form  of  amnesic  aphasia.  At 
other  times  there  is  mutism  with  muscu- 
lar rigidity,  the  patient  being  apparently 
in  a  cataleptic  condition. 

Frequently  there  is  great  motor  rest- 
lessness. The  patient  is  kept  in  bed  with 
difficulty,  and,  if  allowed  to  get  up,  runs 
about  the  room  or  ward,  shouts,  laughs, 
pounds  against  doors,  breaks  windows 
and  furniture,  and  tears  his  clothing. 
He  does  not  control  his  sphincters  and 
passes  urine  and  faeces  into  the  bed  and 
clothing. 

There  is  usually  fever,  with  rapid,  and, 
in  advanced  cases,  feeble  pulse.  The 
tongue  is  dry  and  coated,  there  is  loss  of 
appetite  and  frequently  refusal  of  food, 
although  this  can  usually  be  overcome 
without  resort  to  forcible  feeding. 

Causation. — Probably  toxaemia  in  all 
cases.  The  poisonous  materials  may  be 
absorbed  from  the  intestinal  canal,  from 
wounds  or  septic  areas,  or  may  be  formed 
in  the  blood,  tissues,  or  glands.  They 
may  be  autogenetic  or  introduced  from 
without.  In  some  cases  (Easori.  Kyle, 
Babcock)  organisms  have  been  found, 
but  their  specificity  has  not  been  demon- 
strated. 

Acute  confusional  insanity  occurs  dur- 
ing or  after  infectious  diseases  (typhoid 
fever,  influenza,  pneumonia,  rheuma- 
tism); after  surgical  operations,  in  the 

I  puerperium,  during  lactation,  after  cra- 
nial and  other  traumatisms,  neuritis; 
from  the  ingestion  of  alcohol,  opium,  co- 
caine, lead,  and  other  drugs;  from  the 

I  inhalation  of  certain  poisonous  gases, — 
sulphide  of  carbon,  sulphuretted  hydro- 

|  gen,  etc.    Cerebral  exhaustion,  fright, 


INSANITY.    ACUTE  CONFUSIONAL.  DIAGNOSIS. 


109 


anger,  and  other  psychical  shocks  are 
also  said  to  cause  this  form  of  mental  dis- 
turbance. 

Specific  infection  must  be  included 
among  the  causes  of  mental  symptoms 
and  diseases  which  precede,  accompany, 
or  follow  febrile  and  other  infectious  dis- 
orders. Much  negative  evidence  may  be 
adduced  in  favor  of  acute  delirium  or 
acute  mania's  being  due  to  toxaemia. 
Analogies  with  nervous  affections, 
known  or  believed  to  be  of  microbic 
origin,  favor  the  view  that  insanities 
with  similar  or  related  phenomena  and 
lesions  are  also  microbic  in  origin.  The 
meagre  evidence  afforded  by  careful  bac- 
teriological investigation  of  cases  of 
acute  insanity  seem  to  show  that  various 
micro-organisms  may  induce  the  same  or 
similar  types  of  mental  disease.  The 
mental  disorders  of  pregnancy  and  the 
puerperal  state  are,  in  a  considerable 
proportion  of  cases,  probably  toxsemic, 
without  reference  primarily  to  child- 
birth; but  it  cannot  be  regarded  as 
proved  that  a  bacillus  of  either  eclampsia 
or  puerperal  mania  is  the  sole  cause  of 
these  affections.  C.  K.  Mills  (N.  Y.  Med. 
Jour.,  June  23,  '94). 

Diagnosis. — The  differentiation  must 
be  made  from  mania  and  melancholia. 
The  affection  is  frequently  confounded 
with  the  former.  Many  cases  pro- 
nounced mania,  even  by  expert  alienists, 
belong  to  the  group  of  acute  confusional 
insanities.  Pure  mania — that  is,  typical 
exaltation  without  incoherence — is  not 
as  frequent  as  it  would  appear  to  be  from 
statistical  tables.  Worcester  puts  the 
matter  very  clearly  when  he  says  "there 
are  two  distinct  classes  of  cases,  which 
have  in  common  the  symptoms  of  motor 
restlessness,  loquacity,  destructiveness, 
and  violence.  In  the  one  (mania)  there 
seems  to  be,  at  the  outset  at  least,  an  ex- 
altation of  some  of  the  mental  faculties. 
The  patients  appreciate  perfectly  well 
their  surroundings;  perception  seems 
preternaturally  acute;  memory  appears 


to  be  quickened,  so  that  long-forgotten 
circumstances  are  related  with  the 
utmost  accuracy.  The  patients  show  an 
extraordinary  quickness  in  repartee,  and 
often  a  diabolical  ingenuity  and  cunning 
in  mischief.  They  are  always  ready  with 
an  ingenious  and  plausible  explanation 
of  their  extravagant  conduct.  The  ela- 
tion which  is  present  is  the  natural  reflex 
of  the  feeling  of  unbounded,  unimpeded 
energy.  Hallucinations  are  seldom,  if 
ever,  present;  delusions  may  be  entirely 
wanting,  and,  if  they  exist,  they  are  the 
natural  expression  of  the  emotional  state. 
In  the  other  class,  on  the  contrary  (con- 
fusional insanity),  there  is,  from  the  be- 
ginning, evident  intellectual  impairment, 
which  may  exist  in  any  degree,  even  to 
an  entire  failure  to  rightly  recognize  any 
of  the  persons  and  things  about  the  pa- 
tient, Memory  is  impaired  or  practically 
abolished;  the  acts  of  mischief  and 
violence  are  done  without  any  apparent 
purpose,  and,  when  any  explanation  of 
them  can  be  obtained,  it  is  utterly  irrele- 
vant or  evidently  founded  on  some  pre- 
posterous delusion.  Hallucinations  are 
extremely  common,  and,  with  vague,  in- 
coherent delusions,  dominate  the  whole 
conduct  of  the  patient.  As  a  rule,  there 
is  no  evidence  of  any  feeling  of  elation. 

"The  distinction  between  melancholia 
and  confusional  insanity,  with  depres- 
sion, is  of  the  same  sort.  The  disorder  in 
melancholia  is  primarily  emotional.  The 
patients  appreciate  perfectly  their  sur- 
roundings, they  recognize  persons  and 
things;  they  can  reason  correctly  on 
topics  indifferent  to  them  if  their  atten- 
tion can  be  fixed  upon  them;  their  delu- 
sions are  the  expressions  of  the  over- 
powering feeling  of  impending  evil, 
which  makes  everything  inconsistent 
with  it  seem  incredible.  In  confusional 
insanity,  on  the  contrary,  when  there  is 
the  feeling  of  depression,  it  is  the  result 


HO  INSANITY.    ACUTE  CONFUSIONAL.    TREATMENT.  PUERPERAL. 


of  the  delusions,  which  are  vague,  inco- 
herent, and  illogical." 

Many  of  the  cases  pronounced  "agi- 
tated melancholia"  and  "melancholia 
with  stupor"  are  doubtless  cases  of  con- 
fusional  insanity. 

Prognosis. — The  prognosis  of  acute 
confusional  insanity  is  generally  favor- 
able. While  a  considerable  proportion 
die  from  exhaustion  under  the  custom- 
ary methods  of  treatment,  the  number 
passing  into  dementia  is  comparatively 
small.  The  recovery-rate  should  be, 
under  favorable  conditions  (early  treat- 
ment, careful  nursing)  at  least  75  per 
cent.  The  greatest  danger  is  from  ex- 
haustion. 

Treatment. — The  tendency  to  exhaus- 
tion being  an  ever-present  one  in  acute 
confusional  insanity,  the  first  and  most 
important  requisite  in  the  treatment  is 
rest  in  bed.  Isolation  is  not  necessary, 
and,  in  the  opinion  of  the  writer,  not  de- 
sirable. Patients  may  at  times  be  treated 
successfully  at  home,  but  where  an  insti- 
tution is  accessible,  the  chances  for  re- 
covery are  better  if  the  patient  is  re- 
moved to  one. 

Nutrition  demands  constant  attention. 
Easily-digested  food  in  sufficient  quan- 
tity must  be  provided,  and  the  physician 
should  satisfy  himself  that  the  patient 
gets  it  at  the  proper  times.  Forcible 
feeding  is  rarely  necessary,  but  many  pa- 
tients require  urging  to  eat.  Such  a  one 
is  liable  to  suffer  in  the  hands  of  a  care- 
less nurse  or  attendant.  Stimulants  are 
often  necessary,  especially  in  cases  with 
much  fever. 

The  insomnia  and  delirium  can  often 
be  overcome  by  warm  baths,  but  if  the 
usual  hygienic  means  of  producing  sleep 
fail,  hypnotics  must  be  resorted  to.  Of 
these,  opium  is  to  be  preferred,  on 
account  of  its  stimulant  properties. 
Chloral,  hyoscine,  and  paraldehyde  are 


not  recommended,  the  former  on  account 
of  its  depressant  effect  upon  the  heart, 
and  the  two  latter  because  they  interfere 
with  nutrition.  Next  to  opium,  sulpho- 
nal  and  trional  may  be  cautiously  tried. 
Digitalis,  strophanthus,  and  strychnine 
are  often  of  great  value  to  tone  up  the 
depressed  heart.  The  bowels  should  be 
kept  open  by  mild  saline  purgatives. 

Tincture  of  chloride  of  iron  in  large 
doses  is  often  of  value.  Under  proper 
management,  recovery  is  often  remark- 
ably rapid.  All  sources  of  toxasmic  in- 
fection should  be  sought  for,  and  if  pos- 
sible removed. 

Puerperal  Insanity. 

Definition. — Mental  disturbance  oc- 
curring in  the  puerperal  period,  due  to 
toxsemic  infection.  The  clinical  form  of 
the  disease  is  usually  acute  confusional 
insanity. 

Symptoms  and  Course.  —  The  symp- 
toms of  puerperal  insanity  are  usually 
those  of  acute  confusional  insanity.  The 
outbreak  of  the  disease  usually  occurs  in 
the  first  week  of  the  lying-in  period.  It 
is  in  almost  all,  if  not  in  all,  cases  related 
to  certain  well-known  symptoms  of  puer- 
peral sepsis.  Fever  is  nearly  always  pres- 
ent. Changes  in  the  quantity  and  char- 
acter of  the  lochia  are  frequent.  There 
may  be  prodromic  symptoms,  although 
usually  these  are  not  well  marked.  This 
consists  either  in  depression,  irritability, 
or  emotional  instability.  The  outbreak 
usually  begins  with  excitement,  rapidly 
ending  in  incoherence.  The  usual  feel- 
ings are  perverted.  The  patient  may 
have  attacks  of  violence  during  which  at- 
tempts are  made  on  the  life  of  the  hus- 
band, the  newly-born  child,  or  other 
children,  if  there  are  any.  These  at- 
tempts often  have  a  rekirious  basis:  at 
other  times  they  are  based  upon  delusions 
of  jealousy. 

INot  infrequently  the  hallucinations 


INSANITY.    PUERPERAL.  CAUSATION. 


Ill 


and  delusions  of  the  patient  are  of  a 
sexual  character.  The  most  refined 
women  will  surpass  the  imagination  of 
the  veriest  rake  and  gutter-snipe  in  their 
obscenity  and  vulgarity  of  language  and 
action. 

Motor  excitement  is  common.  There 
is  frequently  a  tendency  to  remove  the 
clothing.  In  some  this  appears  to  be  a 
desire  to  expose  the  body  to  view;  in 
others  it  probably  is  due  to  an  halluci- 
nation of  common  sensation,  rendering 
the  weight  or  pressure  of  the  clothing 
unbearable. 

A  second  stage  following  this  excite- 
ment is  often  one  of  depression.  The 
distinction  from  true  melancholia  is, 
however,  easy.  The  patient  gets  apa- 
thetic, there  may  be  depressive  delusions, 
suicidal  tendencies  may  develop,  and 
there  may  be  alternations  of  excitement 
and  depression,  with  incoherence  as  a 
dominant  symptom,  lasting  for  years. 
While  cases  end  not  infrequently  in 
secondary  dementia,  this  is  not  frequent. 
The  writer  has  seen  an  apparently  com- 
plete recovery  from  puerperal  insanity 
after  six  years'  residence  in  an  asylum. 

The  stuperose  stage  of  confusional  in- 
sanity is  usually  passed  through  by  puer- 
peral cases  on  the  way  to  recovery  or 
dementia. 

Diagnosis. — The  diagnosis  of  puer- 
peral insanity  cannot  be  made  from  the 
symptoms.  It  is  not  a  special  variety  of 
insanity  symptomatically,  but  etiolog- 
ical ly.  The  cases  of  insanity  occurring 
early  in  pregnancy,  which  are  so  often 
classed  with  the  puerperal  insanities, 
have  generally  no  etiological  relation 
with  them.  On  the  other  hand,  cases  of 
lactational  insanity  frequently  belong  to 
the  same  class  of  toxasmic  psychoses. 

Causation. — As  stated  in  the  defini- 
tion, the  writer  believes  puerperal  in- 
sanity to  be  due  to  toxemic  infection. 


The  reasons  for  this  opinion  are  the  fol- 
lowing:— 

1.  Puerperal  insanity  occurs,  in  the 
great  majority  of  cases,  within  the  first 
ten  days  after  delivery — about  one-half 
in  the  first  five  days — the  same  period 
during  which  puerperal  infection  usually 
occurs. 

2.  It  is  usually  accompanied  by  eleva- 
tion of  temperature  and  other  evidences 
of  febrile  disturbance. 

3.  The  clinical  form  in  which  puer- 
peral insanity  manifests  itself  is,  in  the 
majority  of  cases,  that  of  acute,  delirious, 
or  confusional  mania.  Depressive  states 
are  rare  except  as  secondary  forms.  In 
other  words,  the  most  frequent  condition 
is  one  most  closely  resembling  febrile 
delirium. 

4.  The  death-rate  is  much  higher  than 
in  simple  m-ania.  Death  occurs  from  ex- 
haustion, usually  with  high  temperature 
and  rapid  pulse. 

5.  Post-mortem  examinations,  though 
apparently  infrequent  in  these  cases, 
have  shown  grave  involvement  of  the 
pelvic  viscera. 

6.  Examinations  of  the  pelvic  organs 
during  life  show  lacerations  of  the  peri- 
neum and  cervix  uteri  (facile  channels  of 
infection  in  the  puerperal  woman).  As 
secondary  conditions  are  found  intrapel- 
vic  (peritoneal)  inflammations,  and  con- 
sequent abnormal  locations,  fixations, 
and  congestions  of  the  uterus,  tubes,  and 
ovaries. 

Puerperal  infection  is  the  direct  cause 
of  puerperal  insanity.  Out  of  forty-nine 
cases,  well-marked  evidence  of  puerperal 
infection  was  found  in  forty-two,  while 
of  the  remaining  seven  two  were  com- 
plicated with  eclampsia,  the  mental  dis- 
turbance being  transitory.  Twelve  of 
the  cases  proved  fatal.  T.  Hansen  (Cen- 
tralb.  f.  Gynak.,  No.  20.  '88). 

Puerperal  insanity  is  not  a  true  etio- 
logical species,  but  only  an  active,  de- 


112 


INSANITY.    PUERPERAL.  LACTATIONAL. 


lirious  phase  of  mental  degeneracy  and  a 
neuropathic  tendency.  The  hereditary 
taint  and  morbid  predisposition  are  the 
true  cause  of  the  disease,  the  puerperal 
condition  being  -only  its  immediate  and 
exciting  cause.  Out  of  133  cases  cited, 
21  began  during  pregnancy,  55  followed 
parturition,  and  57  occurred  during  lac- 
tation. Z.  Gorsky  ("Considerations  sur 
la  Folie  Puerperale  et  sur  sa  Nature," 
These  de  Paris,  '90). 

Prognosis. — The  prognosis  of  puer- 
peral insanity  is  favorable:  75  to  80  per 
cent,  recover,  but  a  large  proportion  of 
the  remainder  die  of  exhaustion. 

In  no  class  of  cases  of  insanity  is  the 
prognosis  so  favorable  as  in  those  of 
puerperal  origin. 

The  number  of  previous  pregnancies 
seems  to  have  little  influence,  but  the 
age  seems  of  more  importance;  the 
younger  the  patient,  the  better,  appar- 
ently, is  the  prognosis.  J.  E.  McCuaig 
(Med.  News,  Nov.  16,  '95). 

Treatment. — The  principles  of  treat- 
ment indicated  under  acute  confusional 
insanity  are  in  place  here.  Bed-rest, 
good  food,  and  hypnotics  when  necessary, 
are  the  indicated  remedies. 

Bearing  in  mind  that  puerperal  in- 
sanity is  an  infection  psychosis,  the  local 
sources  of  infection  should  be  sought 
out  and  removed  if  possible.  In  some 
cases  there  is  simply  saprgemia  due  to 
absorption  of  septic  materials  from  the 
birth-canal.  Here  the  use  of  douches  of 
hot  water,  medicated  with  antiseptics  or 
not,  are  in  order.  In  cases  of  purulent 
endometritis  curetting  of  the  interior  of 
the  uterus  with  repeated  irrigation  or 
gauze  packing  will  be  required.  In  cases 
where  tubal,  para-  or  peri-  metric  inflam- 
matory disturbances  have  occurred,  the 
proper  procedure  has  always  seemed  to 
the  writer  to  be  the  operative  removal  of 
the  foci  of  infection.  Even  in  cases  of 
long  standing  (two  to  five  years)  the  oper- 
ative removal  of  local  sources  of  irrita- 


tion and  infection  has  resulted  in  entire 
cure  of  the  mental  disturbance. 

Lactational  Insanity. 

Definition. — Mental  disturbance  oc- 
curring during  the  period  of  lactation, 
usually  coming  on  from  six  weeks  to  ten 
months  after  labor.  Prevailing  types: 
confusional  insanity  and  melancholia. 

Symptoms  and  Course. — In  the  de- 
pressed cases  all  the  phenomena  of  mel- 
ancholia are  usually  present.  Frequently 
there  is  simple  depression  without  hallu- 
cinations or  delusions.  Suicidal  tenden- 
cies are  frequent. 

The  cases  usually  described  as  mani- 
acal belong,  in  the  majority  of  instances, 
to  the  acute  confusional  type.  There  are 
varying  hallucinations  and  delusions,  in- 
coherence, refusal  of  food,  generally 
fever,  want  of  control  of  the  sphincters, 
and  a  tendency  to  exhaustion. 

Etiology. — Prolonged  or  excessive  lac- 
tation is  given  as  the  chief  cause  of  in- 
sanity occurring  during  the  nursing 
period.  Careful  inquiry  will,  however, 
show  that  certain  conditions  favoring 
toxamiic  infection  are  often  present. 
Thus,  a  mammitis  or  mammary  abscess 
not  rarely  precedes  the  mental  disturb- 
ance. Defective  uterine  involution  is 
regarded  by  Bevan  Lewis  as  a  factor. 
The  writer  has  found  lacerated  cervix 
and  endometritis  present  in  some  cases. 

Diagnosis. — The  occurrence  of  con- 
fusional insanity  during  the  nursing 
period  is  the  only  diagnostic  feature. 
There  is  nothing  distinctive  in  the  symp- 
tomatology. Between  3  and  4  per  cent, 
of  all  cases  of  insanity  in  women  occur 
during  the  nursing  period. 

Progn  osis. —  Moderately  favorable. 
From  40  to  50  per  cent,  recover.  Clou- 
ston  claims  as  high  a  proportion  as  77 
per  cent. 

Treatment. — Removal  of  local  sources 
of  infection  or  irritation.    Good  food  and 


INSANITY.    SATURNINE.  POST-FEBRILE. 


113 


haematic  tonics  are  usually  indicated. 
Arrest  the  drain  upon  vital  power  by 
stopping  the  nursing. 

Saturnine  Insanity. 

Definition. — Insanity  following  the 
absorption  of  lead. 

Symptoms  and  Cause. — Two  forms  of 
insanity  from  lead  are  described.  In  the 
one  the  patient  is  incoherent,  but  not, 
very  much  disturbed.  In  the  other  there 
is  violent,  noisy  behavior  with  inco- 
herence, followed  by  deep  sleep  or  coma. 
Tremor  and  subsultus  tendinum  are 
usually  present.  At  times  there  are  epi- 
leptiform convulsions. 

Diagnosis. — The  usual  objective  signs 
of  lead  poisoning  are  present. 

Prognosis  and  Treatment. — The  dis- 
ease is  extremely  grave.  About  one- 
fourth  of  the  cases  die  in  the  attack. 
Dementia  may  follow  in  cases  escaping 
death.  The  majority  of  cases  recover 
with  or  without  mental  defect.  The 
treatment  is  that  of  lead  poisoning. 

TJrsemic  Insanity. 

Definition. — Insanity  occurring  in  the 
course  of  Bright's  disease  and  due  to  the 
non-elimination  of  toxic  materials  from 
the  blood. 

Symptoms  and  Course.  —  Christian, 
Alice  Bennett,  Bondurant,  Tuttle,  Bab- 
cock,  and  others  have  shown  statistically 
that  a  large  proportion  of  the  insane  in 
hospitals  and  asylums  in  this  country 
have  chronic  renal  disease.  Irrespective 
of  the  general  etiological  significance  of 
this  fact  is  the  occurrence  of  cases  of  in- 
sanity in  the  course  of  chronic  Bright's 
disease  and  probably  depending  upon 
the  same  causative  factors  as  other  symp- 
toms of  uraemia.  In  a  recent  case  ob- 
served, by  the  writer  there  were  depres- 
sive symptoms  alternating  with  delusions 
of  persecution;  so  that  the  diagnosis  had, 
at  different  periods,  fluctuated  between 
melancholia  and  paranoia.   The  case  ter- 


minated in  ursemic  convulsions  with 
amaurosis.  Maniacal  delirium  some- 
times occurs.  Clouston  refers  to  cases  of 
violent  uraemic  delirium,  ending  rapidly 
in  death.  This  Cyclopedia  (see 
Bright's  Disease,  volume  i)  contains 
abstracts  of  a  number  of  cases  that  show 
the  varying  symptomatology. 

Systematic  examination  of  the  urine 
should  be  part  of  the  routine  in  all  ex- 
aminations of  insane  persons. 

Satisfactory  clinical  observations,  to- 
gether with  post-mortem  findings,  clearly 
demonstrate  the  occurrence  of  pro- 
nounced insanity  as  a  result  of  all  forms 
of  kidney  inflammation  as  well  as  other 
renal  disorders.  In  a  great  majority  of 
these  cases  the  mental  disorder  is  to  be 
attributed  to  uraemic  intoxication.  There 
is  no  special  form  of  insanity  from  renal 
disease,  though  the  different  forms  of 
melancholia  are  those  most  frequently 
observed.  Auerbach  (Allgemeine  Zeit.  f. 
Psych.,  etc.,  B.  52,  H.  2,  '95). 

Literature  of  '96-'97-'98. 

Only  2  cases  of  uraemic  insanity  seen 
among  3000  carefully  observed  lunatics. 
It  appears,  however,  that  uraemia,  both 
acute  and  chronic,  may  lead  to  insanity. 
E.  Bischoff  (Wiener  klin.  Woch.,  No.  25, 
'98). 

Treatment. — In  addition  to  the  usual 
remedies  for  the  uraemic  condition,  mor- 
phine is  often  necessary  to  quiet  restless- 
ness and  delirium. 

Post-febrile  Insanity. 

Definition.  —  Insanity  arising  in  the 
course  of  or  following  infectious  diseases. 

The  ordinary  febrile  delirium  is  not 
included  here,  although  probably  de- 
pending upon  the  same  essential  cause: 
i.e.,  a  toxaemia. 

[Sydenham,  over  two  centuries  ago, 
described  delirium  and  comatose  stupor 
occurring  in  the  course  of  small-pox. 
He  also  referred  to  "a  sort  of  mania 
which  succeeds  long-continued  intermit- 
tent fevers  and  at  last  degenerates  into 


114 


INSANITY.    POST-FEBRILE.  SYMPTOMS. 


idiocy."  Here  is  evidently  meant,  not  a 
transitory  delirium,  but  a  prolonged 
acute  psychosis  terminating  in  dementia. 
In  the  light  of  our  present  knowledge, 
the  explanation  of  Sydenham — "this 
comes  from  weakness  and  vapidity  of  the 
blood  brought  on  by  over-long  fermenta- 
tion"— seems  almost  prophetic.  Benja- 
min Rush  mentions  "fevers  of  all  kinds" 
among  the  causes  of  insanity,  and  refers 
specifically  to  one  case  following  measles. 
Murchison  refers  to  cases  of  mania  and 
imbecility  following  typhus  and  typhoid 
fevers.  In  1880  Kraepelin  collected  over 
four  hundred  cases  of  insanity  occurring 
in  connection  with  febrile  diseases. 
George  H.  Rohe.] 

Insanity  has  been  observed  during  the 
course  of  or  following  typhoid,  typhus, 
and  malarial  fevers,  small-pox,  measles, 
erysipelas,  rheumatism,  gout,  cholera, 
and  influenza.  The  last-named  disease 
has  preceded  insanity  in  a  large  percent- 
age of  cases  occurring  within  the  past 
nine  years. 

It  is  a  comparatively  rare  occurrence 
for  actual  insanity  to  develop  during 
the  course  of  bodily  disease.  Mental 
disease  most  commonly  occurs  after 
fevers,  poisons,  injuries  and  operations, 
and  heart  disease,  and  perhaps  in  this 
order  of  frequency.  In  the  early  stages 
of  fevers  and  after  injuries  and  opera- 
tions, mania  is  the  common  form  of  in- 
sanity, but  in  other  conditions  depression 
is  more  common,  though  the  commonest 
form  is  an  insanity  with  marked  delu- 
sions of  persecution,  often  associated 
with  auditory  hallucinations.  There  is 
no  special  form  of  insanity  connected 
with  special  bodily  disease  with  the  ex- 
ception of  the  condition  which  accom- 
panies alcoholic  paralysis,  and  which  is 
marked  by  a  pronounced  failure  of  mem- 
ory for  time  and  also  for  place.  Insanity 
occurs  with  unusual  frequency  in  bodily 
diseases  associated  with  peripheral  neu- 
ritis, as  in  poisoning  by  alcohol  or 
carbon  monoxide.  Where  the  cause  is 
not  continuous  the  mental  symptoms  in 
the  great  majority  of  cases  disappear. 
Reynolds  (Jour.  Mental  Sci.,  Jan.,  '94). 

Symptoms  and  Course. — The  clinical 


forms  of  mental  disturbance  described  as 
following  febrile  diseases  may  be  confu- 
sional  insanity,  melancholia,  and  mania. 
Purely  exalted  conditions  seldom  occur. 
When  there  is  melancholia,  it  is  usually 
associated  with  hallucinations  and  delu- 
sions. The  hallucinations  and  delusions 
of  the  acute  stage  often  persist  in  the 
.stage  of  dementia. 

[I  have  known  a  case  of  confusional 
insanity  following  erysipelas  in  which, 
seven  years  after  the  acute  outbreak, 
the  hallucinations  of  hearing  and  de- 
lusions of  persecution  and  personality 
are  present  in  their  original  force.  In  a 
case  of  depression  following  influenza 
delusions  of  personality  with  persistent 
mutism  (not  stuporose)  still  remain,  five 
years  after  the  beginning  of  the  attack. 
Thayer  has  reported  a  case  following 
typhoid  fever  in  which  there  were  de- 
pressive symptoms  with  hallucinations 
of  sight  and  hearing.  George  H.  Rohe.] 

Incoherence  with  hallucinations,  illu- 
sions, and  delusions  are  usually  marked 
symptoms  of  post-febrile  insanity.  In 
heavy  drinkers  a  violent  maniacal  de- 
lirium sometimes  occurs  during  the 
height  of  the  febrile  process. 

Febrile  delirium,  during  an  infectious 
disease,  is  an  acute  attack  of  insanity. 
There  are  the  febrile  mental  derange- 
ments proper  to  the  fever  {psychoses 
fcbrilcs),  and  there  is  the  delirium  of 
convalescence  (psychosis  astheniqucs) . 
Toward  the  end  of  acute  infectious  dis- 
eases there  is  the  "delirium  of  inanition." 
which  may  go  on  to  the  delirium  of  col- 
lapse. Weber  (Medico-Chirur.  Trans., 
'65). 

Though  asthenic  delirium  is  the  most 
common  kind  during  convalescence, 
other  kinds  are  met  with,  sensorial  illu- 
sions being  often  present.  There  is, 
probably,  in  such  cases,  a  cerebral  in- 
toxication due  to  microbic  products  of 
the  virus  which  has  set  up  the  disease. 
One  great  distinction  between  the  psy- 
choses of  convalescence  and  the  delirium 
of  fever  lies  in  the  evident  influence  of 
heredity,  and  the  personal  antecedents  of 
the  patient,  upon  the  character  of  the 


INSANITY.    POST-FEBRILE.    TREATMENT.  POST-OPERATIVE. 


115 


delirium  in  the  former  case  (Kraepelin, 
Savage),  in  contrast  to  its  uniform 
course  in  the  latter;  in  fact,  heredity 
appears  to  play  the  chief  part,  and  the 
acute  disease  is  often  only  the  accidental 
cause  of  the  mental  alienation.  Chris- 
tian (Archives  Gen.  de  Med.,  Sept.,  '73). 

Two  cases  complicating  pneumonia 
have  come  under  my  notice.  Clonston 
has  laid  especial  stress  upon  the  mental 
depression  succeeding  influenza.  He 
says  the  last  epidemic  "left  the  mental 
and  nervous  tone  of  Europe  lower  by 
some  degrees  than  it  found  it,"  and  "no 
epidemic  of  any  disease  on  record  has  had 
such  mental  effects."  However  true  this 
may  or  may  not  be  of  Europe,  there  is, 
in  my  opinion,  no  evidence  that  similar 
disastrous  effects  have  followed  the  epi- 
demic in  America. 

Prognosis. — This  is  usually  favorable. 
If  the  patient  escapes  the  dangers  of  ex- 
haustion in  the  acute  stage,  recovery 
takes  place  in  from  70  to  80  per  cent. 

Treatment. — The  treatment  of  post- 
febrile insanity  usually  requires  careful 
attention  to  the  nutritive  functions. 
Tonics  and  stimulants  are  nearly  always 
indicated.  "When  hypnotics  are  neces- 
sary, the  depressive  drugs — chloral,  bro- 
mides, sulphonal  —  should  be  avoided. 
Opium  and  cannabis  Indica  are  often  of 
great  value. 

Post-operative  Insanity. 

Definition. — Insanity  following,  im- 
mediately or  remotely,  operations  upon 
the  body. 

Varieties. — The  occurrence  of  insanity 
as  a  sequel  of  surgical  operations  has  long 
been  known.  The  more  transitory  forms . 
of  mental  aberration,  termed  "trau- 
matic" or  "nervous"  delirium,  are  recog- 
nized by  all  surgeons,  although  probably 
less  frequently  seen  since  the  general 
adoption  of  aseptic  methods  in  surgery. 
Within  the  past  few  years  especial  atten- 
tion has  been  drawn  to  insanity  follow- 


ing operations  upon  the  female  genera- 
tive organs,  and  by  some  this  occasional 
occurrence  of  mental  disturbance  has 
been  held  to  be  a  contra-indication  to  the 
performance  of  such  operations.  It  has 
been  maintained  that  insanity  follows 
removal  of  the  uterine  appendages  with 
especial  frequenc}r,  and  that  therefore 
the  possibility  of  this  unfortunate  com- 
plication should  demand  particular  at- 
tention before  subjecting  a  patient  to 
operation. 

(1)  Cases  of  serious  mental  derange- 
ment may  occur  after  operations  on  pa- 
tients without  any  previous  personal  or 
family  histories  of  insanity;  (2)  mental 
disorders  are  no  more  likely  to  follow 
operations  on  the  sexual  organs  than  on 
any  other  part  of  the  body;  (3)  such 
disorders  occur  just  as  frequently  in 
men  as  in  women;  (4)  operations  are  at 
times  the  determining  cause  of  mental 
derangements  where  there  was  no  pre- 
vious tendency  to  the  disease;  (5)  men- 
tal disturbances  occurring  a  considerable 
time  (months)  after  an  operation  are 
most  probably  independent  of  the  sur- 
gical procedure;  (6)  the  development  of 
psychoses  may  follow  in  those  cases  in 
which  the  convalescence  from  the  opera- 
tion has  been  perfect;  (7)  the  existence 
of  a  predisposition  to  psychoses  should 
stay  the  surgeon's  hand,  except  in  such 
cases  as  are  urgent  and  necessary;  (8) 
mental  derangements  follow  operative 
procedures  with  more  frequency  than  is 
generally  supposed.  J.  M.  Baldy  (Med. 
Age,  Aug.  10,  '92). 

There  is  no  proof  that  genital  irrita- 
tion in  the  male  or  female  can  cause 
nervous  or  mental  disease,  except  in  a 
predisposed  person.  The  proof  is  not  yet 
absolute  that  genital  irritation  can  pro- 
duce nervous  and  mental  disease  even  in 
a  predisposed  person.  L,  C.  Gray  (Trans. 
Med.  Soc.  of  State  of  N.  Y.,  '93). 

Gynaecological  operations  should  be 
performed  on  insane  patients  only  when 
the  physical  condition  endangers  life  or 
renders  it  insupportable.  Patients  should 
be  in  a  calm  frame  of  mind  before  the 
operation  and  previous  moral  treatment 
instituted  before  it  is  undertaken.    A.  H. 


116 


INSANITY.  POST-OPERATIVE. 


McFarland  (Annals  of  Gynaecology  and 
Pediatry,  Oct.,  '93). 

In  all  cases  where  the  menstrual  epoch 
acts  as  the  exciting  cause  of  insanity, 
the  ovaries  should  be  removed,  even  if 
there  is  no  evidence  of  local  disease. 
Eliot  Gorton  (Med.  Rec,  Aug.  25,  '94). 

Out  of  300  castrations,  in  200  cases 
operation  had  a  beneficial  effect;  in  100 
it  was  doubtful  or  unfavorable.  In  2 
personal  cases,  both  said  to  be  cured, 
same  results  could  have  been  reached 
without  mutilation.  Kraemer  (Allge- 
meine  Zeit.  f.  Psych.,  etc.,  B.  52,  H.  1, 
'95). 

The  details  of  a  number  of  cases  of 
mental  disturbance  following  surgical 
operations  leave  much  to  be  desired  on 
the  score  of  fullness  and  accuracy.  In 
perhaps  the  majority  of  instances  authors 
consider  it  sufficient  to  state  that  "in- 
sanity" followed  the  operation.  How- 
ever, enough  is  known  to  warrant  the 
conclusion  that  several  forms  of  mental 
disturbance,  agreeing  in  the  main  with 
certain  prominent  clinical  varieties  of  in- 
sanity, are  met  with  as  such  post-opera- 
tive sequels;  but  there  is  no  special  and 
distinctive  form  of  post-operative  psy- 
chosis. 

There  can  be  little  doubt  that  in  per- 
sons with  emotional  instability  the  shock 
of  a  grave  operation  may  produce  transi- 
tonr  delirium,  or  even  more  persistent 
mental  aberration.  The  frequency  of  the 
so-called  "transitory  mania"  at  the  mo- 
ment of  the  completion  of  the  second 
stage  of  labor  is  evidence  that  .intense 
pain,  combined  with  high  nervous  ten- 
sion, is  capable  of  producing  it.  The 
delirium  attending  severe  injuries — 
"traumatic  delirium" — may  also  in  most 
cases  perhaps  be  ranged  with  the  cases 
of  mental  aberration  from  shock.  Those 
cases  of  post-operative  delirium  or  psy- 
chosis following  immediately  after  the 
operation  may  be  classed  in  this  category. 
That  other  factors  may  concur  in  the 


production  of  this  form  of  psychosis— 
e.g.,  anxiety,  worry,  and  the  like — is 
probable.  Ahlfeld  reported  a  case  of 
violent  mania  following  the  introduction 
of  a  speculum,  and  Kiernan  one  conse- 
quent on  the  passage  of  a  catheter  in  a 
man.  In  a  small  number  of  the  reported 
cases  no  other  essential  factor  than  the 
shock  and  anxiety  can  be  traced.  From 
this  form  the  patient  usually  recovers. 

In  insanity  following  surgical  opera- 
tion mental  impressions  may  be  produced 
in  three  ways:  by  anticipation,  by  actual 
operation,  and  by  after-effects.  C.  T. 
Dent  (Jour,  of  Mental  Science,  Apr.,  '89). 

Literature  of  '96-'97-'98. 

Three  cases  of  mania  after  ovarian  cas- 
tration. One  of  these  recovered  within 
a  month,  while  the  other  two  committed 
suicide.  Poirier  (Rev.  de  Chir.,  April 
and  May,  '98). 

Among  several  thousand  operations, 
only  five  cases  of  insanity  observed,  and 
two  of  these  were  insane  before  the  oper- 
ation; a  third  was  in  a  state  of  senile 
dotage;  in  the  remaining  two  the  mania 
followed  upon  important  operations  and 
was  quite  inexplicable.  The  exaggerated 
fear  of  operation,  which  one  often  meets 
with  in  women,  is  an  important  factor 
in  the  production  of  mental  instability, 
and  is  a  contra-indication,  when  very 
pronounced.  Bouilly  (Rev.  de  Chir., 
April  and  May,  '98). 

The  nature  of  the  operation  does  not 
have  much  influence  on  any  subsequent 
mental  disturbances  which  might  de- 
velop. Hartmann  (Rev.  de  Chir.,  April 
and  May,  '98). 

A  second  class  of  post-operative  in- 
sanity would  appear  to  be  due  to  the  ab- 
sorption of  poisonous  agents  used  before, 
during,  or  after  the  operation.  It  is  now 
generally  accepted  that  the  acute  mental 
disturbances,  mostly  hallucinatory  in 
character,  following  operations  upon  the 
eye  are  due  to  the  use  of  atropine  and 
similar  drugs.    It  is  not  improbable  that 


INSANITY.  POST-OPERATIVE. 


117 


some  of  the  post-febrile  psychoses  are  at- 
tributable to  a  similar  cause. 

These  cases  of  drug  poisoning  with 
pronounced  symptoms  of  mental  disturb- 
ance are  probably  not  so  very  rare  as 
sequelae  of  grave  surgical  operations, 
particularly  where  extensive  use  is  made 
of  chemical  antiseptics  during  the  oper- 
ation or  in  the  after-treatment.  The  ex- 
cessive use  of  opium,  quinine,  and  other 
anodynes  and  antipyretics  may  with  good 
reason  be  charged  with  some  of  the  cases 
of  post-operative  insanity.  The  rare 
cases  of  mental  disturbance  following  the 
administration  of  anaesthetics  may  prop- 
erly be  ranged  under  the  same  heading. 
One  reason  for  this  view  is  that  in  the 
large  majority  of  these  cases  the 
symptoms  are  transitory  and  recovery 
promptly  follows  under  appropriate 
treatment,  the  chief  feature  of  which 
must  be  the  withdrawal  and  elimination 
of  the  toxic  agent. 

Literature  of  '96-'97-'98. 

If  we  exclude  the  pseudomania,  or  de- 
lirium resulting  from  alcoholism,  from 
the  anaesthetic,  from  iodoform,  etc.,  it 
will  be  found  that  real  post-operative 
mania  is  very  rare;  that  the  subjects  of 
it,  while  chiefly  met  with  in  gynaecolog- 
ical practice,  are  the  victims  of  sufficient 
mental  predisposition  to  account  for  its 
occurrence.  Potherot  (Rev.  de  Chir.,  Apr. 
and  May,  '98). 

No  operation  really  "gives  birth"  to  in- 
sanity. Like  the  anaesthetic,  an  operation 
may  reveal  certain  latent  tendencies,  but 
does  not  create  them.  M.  Regnier  (Rev. 
de  Chir.,  Apr.  and  May,  '98). 

A  third  class  of  cases  of  post-operative 
insanity  I  believe  to  be  due  to  the  ab- 
sorption of  septic  materials  from  the 
wound  or  surface  exposed  during  the 
operation.  A  study  of  reported  cases 
shows  that  the  insanity  in  most  instances 
develops  several  days  after  the  operation 


and  is  usually  of  the  clinical  variety 
termed  "acute  confusional  insanity/' 
The  prominent  symptoms  are  insomnia, 
restlessness,  emotional  instability;  some- 
times sudden,  violent  outbreaks,  followed 
by  incoherence,  variable  hallucinations, 
— especially  of  vision, — and  sometimes 
delusions  of  grandeur  or  persecution. 
In  most  cases  there  are  symptoms  of 
fever,  and  usually  marked  implication  of 
the  physical  powers.  The  pulse  is  rapid 
and  weak,  the  temperature  elevated,  the 
tongue  dry  and  red,  and  there  is,  usually, 
refusal  of  food.  Exhaustion  of  mind  and 
body  rapidly  intervenes,  and  the  patient 
sinks  into  a  state  of  muttering  delirium, 
coupled  with  great  bodily  weakness. 

Le  Dentu  has  collected  sixty-eight 
cases  of  post-operative  insanity — thirty- 
eight  following  operations  upon  the  fe- 
male sexual  organs  and  thirty  developing 
subsequent  to  general  operations.  Gen- 
erally, he  says,  the  mental  disturbance 
begins  from  the  second  to  the  fifth  day, 
although  in  some  cases  not  until  the 
twentieth  or  even  later.  He  discusses 
the  possible  causes  of  post-operative  in- 
sanity, but  does  not  offer  a  solution  of  the 
problem.  Bantock,  in  referring  to  a  case 
of  "hysterical  mania"  following  four  or 
five  days  after  an  hysterectomy,  says  there 
was  "considerable  tumefaction  of  the 
mammae  to  account  for  the  disturbance." 

Excluding  the  cases  due  to  shock, 
nervous  strain,  exhaustion,  and  drug-in- 
toxication, which  generally  appear  within 
the  first  twenty-four  hours,  it  is  probable 
that  the  majority,  if  not  all,  of  the  cases 
of  post-operative  insanity  coming  on 
within  the  first  week  are  septic  in  origin. 
Puerperal  insanity  is  now  generally  re- 
garded as  essentially  a  septic  psychosis, 
and  in  this  large  and  well-studied  class 
of  mental  disturbances  we  have  the 
closest  analogy  to  most  cases  of  post- 
operative insanity.    It  is  possible  that 


118  INSANITY.  POST-OPERATIV 

some  of  the  acute  cases  following  re- 
moval of  the  uterus  or  appendages  are 
due  to  the  sudden  induction  of  the  meno- 
pause, for  so  acute  an  observer  as  Krafft- 
Ebing  considers  the  onset  of  the  climac- 
teric as  a  cause  of  acute  delirium.  Those 
cases  of  post-operative  insanity  coming 
on  several  weeks  or  months  after  removal 
of  the  uterus  or  appendages  in  women 
may  be  regarded  as  essentially  cases  of 
climacteric  insanity  (q.  v.).  The  type  is 
usually  depressive.  The  cases  that  have 
been  observed  after  extirpation  of  the 
testicles  also  usually  present  the  melan- 
choliac  type. 

Prognosis. — The  prognosis  of  post- 
operative insanity  is  that  of  confusional 
insanity  generally;  i.e.,  while  the  death- 
rate  from  exhaustion  is  large,  amounting 
to  12  or  15  per  cent.,  the  recovery-rate 
of  the  remainder  is  also  large.  The  cases 
that  terminate  in  secondary  dementia 
probably  do  not  exceed  10  per  cent. 

The  tardy  cases  of  post-operative  in- 
sanity so-called — those  that  come  on  in 
women  from  six  weeks  to  three  or  four 
months  after  removal  of  the  uterus  or 
appendages — give  a  less  favorable  prog- 
nosis. The  recovery-rate  in  these  cases  is 
not  over  50  per  cent.:  about  the  same  as 
that  of  undoubted  climacteric  insanity. 

Literature  of  '96-'97-'98. 

Reports  of  109  cases  in  which  ablation 
of  the  internal  organs  of  generation  was 
undertaken  for  the  cure  of  hysteria  and 
insanity,  or  other  neuropathic  conditions. 
Only  17  were  affected  beneficially.  The 
remaining  92  were  either  uninfluenced  or 
affected  injuriously.  Insanity  afterward 
developed  in  44  of  these  women,  20  of 
whom  had  suffered  from  hysteria  before 
the  operation,  while  24  had  not.  Twenty- 
three  others  who  were  insane  and  hys- 
terical prior  to  the  operation  were  worse 
after  it.  Two  not  previously  hysterical 
had  become  so.  The  remaining  23,  who 
had  been  in  part  insane  and  in  part  hys- 
terical, remained  in  the  same  state  after 


PROGNOSIS.  TREATMENT. 

operation.  Angelucci  and  Pieraccini 
(Riv.  Sper.  di  Freniatria,  p.  290,  '97). 

Of  642  cases  of  hysterectomy  and  bi- 
lateral ovariotomy,  only  4  personally 
observed  in  which  the  operation  was  fol- 
lowed by  psychoses,  and  in  all  of  them 
the  patients  were  predisposed  by  inheri- 
tance or  other  factors.  M.  Segond  (Rev. 
de  Chir.,  Apr.  and  May,  '98). 

Mental  disturbance,  developing  soon 
after  operation,  seldom  proves  serious, 
while,  when  it  appears  a  few  months 
later,  the  prognosis  is  usually  unfavor- 
able.  Jacobs  (La  Policlinique,  Apr.,  '96). 

A  systematic  examination  of  all  female 
insane  patients,  aided  in  nearly  every 
case  by  anaesthesia,  gave  the  startling 
result  that  93  out  of  100  insane  women 
had  pelvic  disease.  Eighty-nine  were 
operated  upon  with  the  result  of  37.5  per 
cent,  mental  recoveries;  22.5  per  cent, 
improved;  35  per  cent.,  unchanged;  5 
per  cent,  of  deaths.  A.  T.  Hobbs  (Jour. 
Mental  Science,  Jan.,  '98). 

Sixty  per  cent,  of  the  insane  women 
personally  examined  had  some  abnormal 
condition  of  the  pelvic  organs,  distinctly 
pathological  and  easily  recognized.  The 
primary  question  is  relief  of  local  dis- 
ease; the  insane  woman  has  the  same 
right  to  treatment  as  the  sane,  and  if 
such  treatment  is  likely  to  benefit  the 
mental  condition  it  is  our  duty  to  carry 
it  out.  A  summary  of  34  cases  shows  11 
complete  recoveries  (mental  and  phys- 
ical), 9  improved.  11  unimproved  in  men- 
tal condition,  and  3  deaths.  Rohe  (Jour. 
Mental  Science,  Jan.,  '98). 

Treatment. — In  the  developed  psycho- 
sis the  treatment  heretofore  recom- 
mended for  confusional  insanity  is  in- 
dicated. Much  may  doubtless  be  done 
in  the  way  of  prophylaxis.  Strict  aseptic 
precautions  during  operation,  removal  of 
all  sources  of  irritation,  both  physical 
and  psychical,  in  persons  of  neuropathic 
constitution  requiring  operation,  and 
I  careful  attention  to  nutrition  in  those 
broken  down  in  health  from  long-con- 
tinued, painful,  or  exhausting  disease, 
will  tend  to  diminish  the  number  of  cases 
1  of  insanity  following  surgical  operations. 


INSANITY.    INSOLATIONAL.  PUBESCENT. 


119 


The  use  of  chemical  antiseptics  and  dis- 
infectants in  this  connection  also  de- 
serves attention. 

Literature  of  '96-'97-'98. 

There  are  many  cases  of  women  who 
have  become  insane  through  irritation  of 
the  ovaries  who  might  derive  benefit 
from  surgery.  The  argument  that  the 
operation  entails  sterility  on  the  women 
is  of  no  weight,  as  such  women  are  likely 
to  bear  unhealthy  children  and  thus 
propagate  thur  neuroses.  Kroemer 
(Therap.  Monats.,  Apr.,  '96). 

Insolational  Insanity. 

Definition. — Insanity  following  insola- 
tion, or  sun-stroke. 

Symptoms. — After  recovery  from  an 
attack  of  sun-stroke  many  persons  surfer 
from  certain  indefinable  changes  in  their 
character.  They  are  more  irritable, 
easily  exhausted,  especially  in  hot 
weather,  and  are  liable  to  vertigo  and 
other  neurotic  troubles.  In  a  small  per- 
centage of  cases  insanity  follows.  This 
was  already  noted  by  Benjamin  Rush, 
who  reports  two  cases  of  madness  caused 
by  insolation. 

The  form  in  which  insolational  insan- 
ity occurs  may  be  maniacal  or  depressive. 
In  the  former  there  may  be  sexual  excite- 
ment with  delusions  of  grandeur  and  un- 
tidy habits.  The  depressive  form  is 
usually  attended  by  suicidal  tendencies, 
delusion  of  persecution,  anxiety,  and  hal- 
lucinations of  sight  and  hearing.  In 
some  cases  defective  memory  is  the  most 
notable  psychical  symptom.  This  may 
be  accompanied  by  motor  disturbances 
simulating  general  paresis. 

Most  writers  who  discuss  insolational 
insanity  class  it  with  the  traumatic  in- 
sanities, assuming  the  evidences  of  me- 
ningeal inflammation,  sometimes  found, 
to  be  the  causes  of  the  mental  disturb- 
ance. It  seems  to  the  writer,  however, 
that  the  condition  of  the  blood  and  ves- 
sels found  post-mortem  in  cases  dying  of 


sun-stroke  indicate  such  a  profound 
change  as  can  only  be  attributed  to  the 
action  of  a  toxin.  So  it  has  seemed 
preferable  to  group  the  insolational 
psychoses  with  those  due  to  toxaemia. 

Prognosis. — Complete  restoration  of 
mental  function  is  rare.  A  modified  re- 
covery, a  partial  dementia,  is  not  infre- 
quent. 

Treatment. — This  is  purely  symptom- 
atic. Persons  who  have  once  suffered 
sun-stroke  should  avoid  exposure  during 
hot  weather. 

Group  VII.  Psychoses  due  to  De- 
velopmental Changes  in  the  Brain. 
(See  also  Infantile  Myxedema.) 

Pubescent  Insanity. 

Definition. — Insanity  occurring  during 
the  pubescent  period  of  life. 

By  the  "pubescent  period"  is  not 
meant  the  arrival  of  the  subject  at  the 
period  of  puberty,  but  the  completion  of 
the  period  during  which  the  repro- 
ductive function  is  fully  developed.  This 
would  include  that  period  commonly 
called  adolescence.  The  completion  of 
this  period  in  the  female  sex  has  been 
established  by  Matthews  Duncan  at 
about  the  age  of  twenty-five  years. 
Clouston  assumes  this  to  be  correct  for 
both  sexes. 

There  is  a  variety  of  periodical  in- 
sanity beginning  with  puberty,  coinci- 
dent with  disturbances  of  menstruation 
and  ending  when  that  function  is  regu- 
lated. It  is  to  be  differentiated  from 
the  usual  forms  of  periodical  menstrual 
insanity,  and  may  be  termed  menstrual 
developmental  insanity.  Friedmann 
(Schmidt's  Jahrbiicher,  Apr.,  '94). 

Symptoms  and  Course.  —  By  some 
authors  a  form  of  mental  disturbance 
termed  hebephrenia  is  described  as  the 
characteristic  form  of  pubescent  insanity. 
Hebephrenia  is,  however,  in  the  majority 
of  cases  simply  another  name  for  the  first 


120 


INSANITY.    PUBESCENT.  TREATMENT. 


stage  of  paranoia.  It  includes  the  cases 
of  so-called  "moral  insanity,"  which  is 
usually  merely  a  stage  in  the  develop- 
ment of  paranoia  (q.  v.).  Clouston,  who 
has  made  a  philosophical  study  of  this 
period  of  life,  both  in  its  normal  and  its 
pathological  relations,  describes  pubes- 
cent insanity  as  follows: — 

"The  insanity  of  puberty  in  both  sexes 
is  characterized  especially  by  motor  rest- 
lessness. Such  patients  never  sit  down 
by  night  or  day  and  never  cease  moving. 
There  is  noisy  and  violent  action,  some- 
times irregular  movements,  or,  in  the 
few  melancholic  forms  and  melancholic 
stages  of  the  maniacal  cases,  cataleptic 
rigidity.  The  mental  symptoms  consist 
most  frequently  in  a  kind  of  incoherent 
delirium  rather  than  any  fixed  delusional 
state.  In  boys  the  beginning  of  an  at- 
tack is  frequently  ushered  in  by  a  dis- 
turbance in  the  emotional  condition — • 
dislike  to  parents  or  brothers  or  sisters 
expressed  in  a  violent,  open  way;  there 
is  irrational  dislike  to  and  avoidance  of 
the  opposite  sex.  The  manner  of  a 
grown-up  man  is  assumed,  and  an  offen- 
sive 'forwardness'  of  air  and  demeanor. 
This  soon  passes  into  maniacal  delirium, 
which,  however,  is  not  apt  to  last  long. 
It  alternates  with  periods  of  sanity  and 
even  with  short  periods  of  depression." 

According  to  my  observation,  this  is  a 
true  picture  of  the  insanity  of  the  pubes- 
cent period.  The  patients  often  recover 
in  a  short  time  after  the  beginning,  of  the 
attack,  but  relapses  are  frequent.  In 
girls,  exacerbations  are  likely  to  occur  in 
connection  with  the  mentrual  periods. 

In  those  cases  which  do  not  recover, 
a  mild  form  of  dementia,  resembling  im- 
becility, follows.  Maniacal  states  are,  on 
the  whole,  more  frequent  than  those  of 
depression.  When  the  latter  are  present 
they  often  have  a  religious  tinge. 

Masturbation,  which  most  authors  re- 


gard as  an  important  concomitant,  has 
probably  little  importance  as  a  symptom. 

Literature  of  '96-'97-'98. 

Adolescent  insanity  is  a  pure  psy- 
chosis, dependent  upon  hereditary  fac- 
tors and  acquired  conditions  which  espe- 
cially inhibit  the  higher  psychical  centres 
and  later  the  sensory  motor  functions  of 
the  cortex;  the  vasomotor  and  trophic 
centres  are  involved  in  it;  the  sympa- 
thetic, nervous  function  is  disturbed, 
from  which  it  is  apt  to  end  eventually, 
in  the  female,  in  suppressed  menstrua- 
tion, or  even  excitation,  producing 
nymphomania;  masturbation  is  a  com- 
plication which,  in  the  male,  is  apt  to 
cause  reflexes;  there  is  no  period  in  life 
more  important  than  adolescence.  F.  P. 
Norbury  (Nashville  Jour,  of  Med.  and 
Surg.,  Nov.,  '97). 

Prognosis. — Authors  usually  give  a 
very  unfavorable  prognosis  in  pubescent 
insanity.  Excluding  those  cases,  how- 
ever, in  which,  from  their  symptoma- 
tology, belong  to  paranoia,  I  regard  the 
prognosis  as  favorable.  Under  appropri- 
ate management  pubescent  insanity  is  a 
hopeful  form  of  mental  disturbance. 
Clouston  reports  that  about  one-half  of 
his  cases  recovered. 

Treatment. — The  treatment  of  pubes- 
cent insanity  should  be  tonic  and  recon- 
structive. If  the  patient  appears  to  be 
too  active  in  movement,  he  should  be  put 
to  bed  and  carefully  fed.  Weighings 
should  be  made  weekly  to  determine  the 
bodily  gain  or  loss.  So  long  as  the  pa- 
tient gains,  he  is  doing  well;  if  he  loses 
weight,  it  is  the  duty  of  the  physician  to 
ascertain  the  cause. 

The  tendency  to  sexual  excitement  and 
to  masturbation  should  be  counteracted 
in  a  moral  way.  The  administration  of 
anaphrodisiacs  is  generally  followed  by 
more  harm  than  benefit.  Mechanical  re- 
straint of  the  insane  for  any  purpose  is 
bad  practice.    It  is  better  to  allow  a  pa- 


INSANITY.    CLIMACTERIC.  SYMPTOMS. 


121 


tient  to  masturbate  than  to  put  him  in  a 
straight-jacket,  or  confine  his  hands  in  a 
"muff." 

Climacteric  Insanity. 

Definition. — Insanity  occurring  dur- 
ing the  period  of  sexual  involution  in 
women. 

Among  the  more  serious  accompani- 
ments of  the  menopause  is  mental  dis- 
order. Statistics  show  that  insanity  in 
women  is  especially  frequent  between  the 
ages  of  forty  and  fifty  years.  As  this  is 
also  the  ordinary  period  of  cessation  of 
the  menses,  the  conclusion  seems  reason- 
able that  some  relation  exists  between 
the  two  conditions,  although  it  must  not 
be  assumed  that  mental  disturbances  at 
this  period  are  necessary  consequences 
of  changes  in  the  functional  activity  of 
the  sexual  organs. 

Symptoms. — Any  of  the  clinical  vari- 
eties of  mental  disorder  may  be  present 
during  the  climacteric;  but  melancholia 
is  most  frequent.  In  22  cases  studied  by 
Goodall  and  Craig,  melancholia  was  pres- 
ent in  66  per  cent.  In  21  cases  under  my 
observation  exactly  the  same  proportion 
were  of  depressive  forms  at  the  time  they 
came  under  notice.  Bevan  Lewis  states 
that,  at  the  early  evolution  of  climacteric 
insanity,  painful  mental  states  invariably 
prevail,  and  in  the  large  majority  of 
cases  mental  depression  exists  through- 
out the  attack. 

Hallucinations  of  hearing  and  of  smell 
are  frequent.  Eeligious  delusions  color 
most  cases.  The  class  of  cases  termed 
by  Savage  "unpardonable  sinners'7  are 
especially  frequent  among  women  who 
become  insane  during  the  climacteric. 
Bevan  Lewis  refers  to  these  cases  in  the 
following  terms:  "Delusional  states  were 
recognized  in  73  per  cent.,  and  out  of  a 
total  of  sixty-one  deluded  cases,  sixteen 
were  victims  to  the  terrible  delusion  that 
the  soul  was  eternally  lost,  and  that  the 


subject  was  to  be  consigned  to  the  names 
of  hell.  It  is  strange  to  witness  the 
prevalence  of  this  religious  despondency 
at  a  period  when,  as  we  are  aware,  the 
generative  organs  are  undergoing  an  im- 
portant cyclical  transformation,  and  to 
contrast  it  with  the  converse  states  of 
religious  exaltation  so  frequently  asso- 
ciated with  the  sexual  transformation 
and  excitation  of  adolescence,  of  hyster- 
ical and  epileptic  forms  of  insanity." 

The  fear  of  death,  immediately  im- 
pending or  more  or  less  remote,  is  often 
present.  Frequently  the  memory  and 
judgment  are  but  little  impaired,  but  the 
patients  complain  loudly  of  confusion  of 
thought,  fear  they  will  become  insane, 
will  never  recover,  etc. 

Delusions  and  hallucinations  referable 
to  the  sexual  sphere  are  common.  Most 
cases  of  pseudocyesis  occur  during  the 
climacteric.  Fear  of  grave  disease  of  the 
pelvic  organs  is  often  present.  The  sub- 
jective sensations  of  itching  and  burning 
in  the  external  organs  and  the  presence 
of  leucorrhcea  are  probably  the  causes  of 
this  morbid  fear.  Actual  disease  of  the 
sexual  organs  is,  however,  often  present, 
and  all  cases  should  be  thoroughly  exam- 
ined to  determine  this  point.  The  great 
frequency  of  uterine  cancer  at  this  period 
of  life  must  not  be  overlooked. 

Delusions  referred  to  the  digestive  or- 
gans are  also  present,  although  not  char- 
acteristic. One  case  insisted  that  her 
internal  organs  were  all  decayed,  and 
that  therefore  it  was  useless  to  give  her 
food  or  medicine.  If  she  had  a  stomach, 
she  might  possibly  recover,  but  as  this 
organ  had  been  entirely  destroyed  there 
was  no  possibility  of  ever  getting  well. 
Another  case  insisted  that  her  entrails 
had  been  taken  out  and  thrown  to  the 
chickens.  On  her  admission  to  hospital 
she  refused  food,  but  after  several  days' 
forcible  feeding  she  began  to  eat  and  im- 


122 


INSANITY.    CLIMACTERIC.  TREATMENT. 


proved  rapidly  in  her  physical  condition. 
Her  delusions  gradually  disappeared  and 
she  was  discharged  recovered  after  two 
months'  treatment. 

Delusions  of  grandeur  are  sometimes 
present  in  the  maniacal  and  paranoiac 
cases. 

Suicidal  tendencies  are  frequent,  al- 
though usually  not  so  persistent  as  in 
melancholia  generally.  In  one  case, 
however,  the  patient  set  fire  to  her 
clothing  "to  escape  from  the  devil,"  and 
was  so  severely  burned  as  to  result  in 
death.  Lewis  refers  to  a  case  in  which 
an  attempt  at  self-destruction  was  made 
to  escape  a  similar  alleged  danger.  The 
apprehension  of  death  by  fire  is  frequent. 

In  some  cases  the  depression  and  men- 
tal anxiety  lead  to  the  use  of  alcoholic 
stimulants,  resulting  often  in  confirmed 
intemperance. 

While  there  is  no  specific  form  of 
mental  disorder  that  can  be  properly 
termed  "climacteric  insanity,"  there 
can  be  no  doubt  that  the  menopause 
must  be  considered  as  one  of  the  exciting 
causes  of  mental  disease. 

Table  of  100  cases  showing  truth  of 
Morel's   statement   that,   although  the 
brain  is  always  the  seat  of  insanity,  it  is 
not  always  the  seat  of  its  cause.    In  17 
cases  distinct  post-climacteric  atrophy; 
9,  enlarged  uterine  cavities;  12,  enlarged 
cervices;  43,  erosions  of  varying  degrees 
of  severity;    7,  lacerated  cervices;  17, 
retroversion;    3,  anteversion;    7,  latero- 
version,  etc.    Clara  Barrus  (Amer.  Jour, 
of  Insanity,  Apr.,  '95). 
Some  writers  devote  much  attention  to 
the  consideration  of  a  climacteric  insan- 
ity in  the  male  sex,  but  there  is  no  period 
in  the  life  of  man  that  corresponds  with 
the  menopause  in  women.    The  parallel 
that  has  been  drawn  between  the  period 
of  involution  of  the  sexual  power  in  man 
and  the  climacteric  period  in  women 
is,  as  Bevan  Lewis  says,  "more  fanciful 
than  strictly  correct." 


Prognosis. — The  prognosis  of  the  in- 
sanities of  the  menopause  is,  according  to 
authors,  rather  favorable.  In  my  cases, 
including  even  those  who  had  already 
passed  into  dementia  when  they  came 
under  observation,  the  recovery-rate  was 
43  per  cent.  Goodall  and  Craig  had  38 
per  cent,  of  recoveries;  Sutherland  a 
fraction  over  40  per  cent.;  Lewis  48  per 
I  cent.;  Merson  nearly  50  per  cent;  Skae 
53.5  per  cent.,  and  Clouston  57  per 
cent. 

Death  is  rare  as  an  immediate  conse- 
quence of  the  psychical  derangement. 
Suicide  and  marasmus  in  those  cases  re- 
fusing food  form  the  largest  contingent 
of  deaths  in  the  acute  condition.  Among 
the  chronic  cases,  tuberculosis  claims  the 
largest  share  in  the  death-rate. 

Treatment. — The   treatment   of  the 
mental  disturbances  of  the  menopause 
often  tests  severely  the  patience  as  well 
as  the  therapeutic  resources  of  the  prac- 
titioner.   Refusal  of  food  often  depends 
upon  delusions,  but  at  times  disorders  of 
the  primce  vice  are  responsible.    In  the 
latter  case  stomach-washings,  laxatives, 
and  intestinal  tonics  such  as  nux  vomica 
and  physostigma  are  indicated.  "Where 
j  the  reluctance  to  take  food  or  its  absolute 
|  refusal  depends  upon  delusions  that  the 
food  is  poisoned  or  that  the  viscera  are 
j  decayed,  forcible  feeding  must  generally 
I  be  resorted  to.    In  cases  of  aggravated 
gastric  catarrh  the  subcutaneous  infusion 
I  of  a  nutritive  saline  solution  heretofore 
recommended  will  often  be  beneficial. 
After  a  few  days'  rest  the  stomach  will 
take  up  its  functions  with  renewed  vigor. 
The  precordial  anxiety  and  palpita- 
I  tion  of  the  heart,  if  troublesome,  will 
generally  yield  to  moderate  doses  of 
Hoffman's  anodyne.    For  insomnia,  pa- 
raldehyde is  probably  the  least  harmful 
hypnotic  that  can  be  used,  although, 
where  its  odor  and  taste  are  objection- 


INSOLATION. 

able  and  there  is  no  cardiac  weakness, 
trional  may  be  substituted. 

The  physical  depression  needs  good 
food,  fresh  air,  and  tonic  medication.  In 
states  of  great  weakness  absolute  confine- 
ment to  the  bed  is  necessary  to  prevent 
exhaustion. 

Symptoms  referable  to  the  sexual  or- 
gans are  not  always  evidence  of  delusion, 
and  should  not  be  so  declared  until  a 
careful  physical  examination  has  shown 
the  absence  of  local  disease. 

Mental  depression  is  best  combated  by 
cheerful  surroundings,  out-door  life,  and 
medicinally  by  opium.  This  drug  should 
be  given  systematically,  as  recommended 
in  melancholia.  Cannabis  Indica  and 
belladonna  are  also  at  times  useful.  Co- 
caine has  been  recommended,  but  is 
dangerous  on  account  of  the  tendency  to 
establish  a  habit. 

The  good  effects  of  thyroid  extract  re- 
ported, especially  in  melancholia,  en- 
courages to  further  trial  with  it. 

The  depressive  hypnotics  and  seda- 
tives— such  as  chloral,  bromides,  sulpho- 
nal,  antipyrine,  etc. — should  generally  be 
avoided  in  depressive  mental  states. 

GrEOKGE  H.  EOHE, 

Baltimore. 

INSECT-BITES  AND  STINGS.  See 

Wounds,  Poisoned. 

INSOLATION. 

Synonyms. — Sun-stroke;  heat-stroke; 
thermic  fever. 

Definition. — The  terms  "insolation," 
"sun-stroke,"  "heat-stroke,"  and  "ther- 
mic fever"  are  applied  to  a  series  of 
symptoms  occurring  as  the  result  of  ex- 
posure to  undue  heat  of  the  whole  or 
parts  of  the  system,  while  the  latter  is  in 
a  condition  of  physical  debility,  and  re- 
sulting from  intoxication  by  products  of 
metabolism. 


SYMPTOMS.  123 

Symptoms. — The  symptoms  vary  in 
intensity  and  nature,  and  three  forms  of 
insolation  are  recognized:  heat-prostra- 
tion, heat-apoplexy,  and  thermic  fever. 

Heat-prostration. — This  form  is 
frequently  observed  in  cities  during  sum- 
mer-heat, especially  in  persons  in  whom 
the  powers  of  resistance  have  been  weak- 
ened by  alcoholism,  ill  health,  and  over- 
work. It  is  also  the  variety  of  insolation 
usually  observed  in  soldiers,  and  is  espe- 
cially marked  in  men  unused  to  march- 
ing or  who  are  laboring  under  a  malarial 
toxaemia.  These  two  associated  varieties 
as  described  by  de  Santi  illustrate  thor- 
oughly the  series  of  phenomena  most  fre- 
quently met  with  in  active  practice. 

In  the  form  characterized  by  indi- 
vidual weakness,  the  man  who  has  so  far 
marched  well  becomes  silent,  unbuttons 
his  coat,  and,  if  asked,  complains  of 
violent  headache  and  oppression;  but  he 
continues  his  march  up  to  the  moment 
when  he  becomes  pale  and  falls,  with 
convulsive  movements,  as  if  in  an  attack 
of  epilepsy.  The  teeth  are  firmly  closed, 
the  insensibility  is  absolute,  the  respira- 
tion difficult,  the  pulse  small  and  irregu- 
lar, and  he  often  urinates  involuntarily. 
A  waxy  pallor  of  the  face  appears  also. 

The  patient  moans,  he  streams  with 
sweat,  he  drags  in  the  rear,  and  if  he 
continues  his  march  he  becomes  still 
paler,  while  his  lips  become  cyanosed; 
the  jugular  and  temporal  veins  swell; 
the  eyes  become  injected;  the  respira- 
tions shallow  and  quick,  until  the  suf- 
ferer falls  gently  to  the  ground.  He 
generally  does  not  entirely  lose  con- 
sciousness, and,  when  he  is  laid  down 
and  relieved  of  everything  which  inter- 
feres with  respiration,  breathes  deeply 
and  quickly  becomes  himself  again. 
Sometimes,  however,  on  coming  around, 
various  nervous  symptoms,  usually  not 
important,  supervene. 


124  INSOLATION. 

The  malarial  form  generally  occurs  in 
old  soldiers  who  have  long  struggled 
with  paludism.  The  man  marches  badly 
on  starting,  but  becomes  more  animated 
as  he  goes  along.  His  face  is  red,  he 
does  not  seem  to  feel  the  fatigue,  but  is 
thirsty;  suddenly,  as  if  struck  down  by 
a  club,  he  falls  face  downward  in  a  state 
of  absolute  coma.  Here,  generally  the 
face  is  turgid,  but  sometimes  it  is  pale. 
This  state  may  last  for  hours, — twenty- 
four  or  thirty-six, — and  may  terminate 
in  death,  without  recovery  of  conscious- 
ness. 

Series  of  31  cases:  in  19  the  heat  pre- 
disposing to  the  attack  was  solar,  in  11 
it  was  artificial,  while  in  2  both  factors 
were  at  work.  The  highest  temperature 
attained  was  112°  R,  more  of  the  cases 
having  temperatures,  upon  reception,  be- 
tween 110°  and  111°  F.  than  between 
any  other  two  degrees.  Twenty  of  the 
cases  were  unconscious,  8  were  conscious, 
and  3  were  partially  conscious,  while  4 
were  wildly  delirious.  Consciousness 
was  maintained  in  every  case  where  the 
temperature  was  below  108°  F.,  except 
in  one,  where  the  temperature  was 
102.4°  F.  The  pupils  in  24  cases  were 
extremely  contracted,  in  5  they  were 
natural,  in  1  they  were  sluggish,  while 
in  1  only  they  were  dilated.  Where  the 
pupils  were  contracted  there  was  also 
present  unconsciousness,  except  in  3 
cases,  and  in  these  the  temperature  was 
106°  or  over.  Convulsions  occurred  in 
but  G  cases.  The  pulse  varied  much  in 
different  cases,  being  invariably  absent 
at  the  wrist,  where  the  temperature 
reached  108°  F.  Respiration  in  almost 
all  cases  Mas  accelerated.  Color  of  the 
face  varied  from  flushed  in  the  lighter 
cases,  to  livid  and  mottled  in  the  cases 
with  marked  alteration  in  respiration 
and  circulation.  Involuntary  evacuation 
of  liquid,  offensive  stools  was  present  in 
many  of  the  cases,  with  the  typical 
mousy,  repulsive  odor  characteristic  of 
these  discharges.  The  longest  time  re- 
quired to  reduce  temperature  to  within 
safe  limits  was  within  one  hour,  the 
average  time  being  from  ten  to  fifteen 


SYMPTOMS. 

minutes.  The  prognosis  could  be  made 
easily  from  the  facility  with  which  the 
temperature  was  reduced.  The  mortality 
in  the  whole  series  was  12  out  of  31. 
The  manner  of  death  was,  as  a  rule,  by 
almost  simultaneous  cardiac  and  respira- 
tory failure.  F.  A.  Packard  (Amer. 
Jour.  Med.  Sci.,  June,  '88). 

The  temperature,  at  first  subnormal, 
generally  rises,  especially  in  mild  cases, 
to  below  102°  or  103°  F.  Recovery 
usually  takes  place  in  a  couple  of  days 
under  proper  treatment.  Mild  cases  may 
recover  in. a  few  hours. 

The  sequela?  most  frequently  observed 
in  cases  of  heat-exhaustion  are  undue 
sensitiveness  to  even  moderate  tempera- 
tures; acceleration  of  the  pulse  and  res- 
piration; disorders  of  digestion;  head- 
ache and  vertigo;  tenderness  of  the 
spine.  Chromatopsia;  irritability  of 
disposition,  particularly  recurring  with 
the  onset  of  warm  weather.  Epilepsy 
and  disorders  of  locomotion  and  sensa- 
tion have  also  been  observed.  Impair- 
ment of  memory  and  of  the  general 
aptitude  are  often  observed. 

The  reflexes  were,  as  a  rule,  exagger- 
ated in  a  series  of  cases  observed  among 
soldiers.  In  4  cases,  epilepsy  appeared 
after  the  insolation;  in  2,  partial  hemi- 
plegia; in  9,  cutaneous  anaesthesia;  in 
3,  hyperesthesia.  The  mental  faculties 
were  impaired.  In  the  majority,  mem- 
ory was  enfeebled.  One  case  presented 
marked  muscular  tremors;  in  27,  there 
was  deafness.  Twenty-six  presented  im- 
pairment of  vision.  Sighing  respiration 
was  a  not  infrequent  manifestation.  In 
14  cases  the  heart  was  irritable;  in 
each  of  15  a  cardiac  murmur  was  heard. 
In  many  of  the  cases  the  murmur  was 
dependent  upon  the  anaemia;  in  some  it 
was  organic.  In  some  cases  the  heart 
was  irregular  or  intermittent.  Barlow 
(Cincinnati  Lancet-Clinic.  June  6,  '91). 

Case  of  a  laborer,  31  years  old.  who, 
while  at  work,  in  midsummer,  lost 
consciousness.  For  some  five  weeks  he 
was  delirious.  During  convalescence 
there  was  difficulty  of  speech  and  im- 


INSOLATION. 

paired  motility  and  sensibility  in  the  ex- 
tremities. The  man  could  not  whistle; 
there  was  slight  drooping  of  the  lower 
lip  on  the  left  side;  there  was  wasting 
of  the  muscles  of  the  shoulder,  and 
fibrillar  tremor  of  these  and  of  the  biceps 
and  triceps;  if  the  arms  were  grasped 
below  the  elbow  a  coarse,  purring  thrill 
was  felt;  the  muscles  of  the  buttocks, 
of  the  thighs,  and  of  the  calves  also 
presented  fibrillar  tremor;  there  was 
slight  tremor  of  the  lips  and  marked 
tremor  of  the  tongue;  there  was  persist- 
ent, dull,  aching  pain  in  the  dorsal  and 
lumbar  regions;  the  knee-jerks  were, 
perhaps,  slightly  subnormal;  the  mus- 
cles presented  slight  quantitative  electric 
changes;  the  sphincters  were  competent; 
the  hands  and  feet  were  cold  and  livid. 
Two  applications  of  the  white-hot  cau- 
tery to  the  back  were  followed  by  a  dis- 
appearance of  the  pain  and  by  decided 
improvement  in  the  symptoms.  Dercum 
(Univ.  Med.  Mag.,  June,  '91). 

Literature  of  '96-'97-'98. 

Case  of  insolation  accompanied  by 
hemiplegia  in  a  boy,  aged  four  years. 
Arthur  F.  Messiter  (Lancet,  June  26, 
'97). 

Heat- apoplexy. — This  form  is  much 
less  frequently  observed.  It  resembles 
to  a  great  degree  the  variety  of  heat- 
exhaustion  occurring  in  people  suffering 
from  malarial  poisoning.  Dizziness,  in- 
tense local  headache,  the  appearance  of 
muscle  volitantes,  marked  throbbing  at 
the  temples,  dryness  of  the  skin,  and 
dyspnoea  are  the  most  usual  premonitory 
symptoms.  Suddenly  the  sufferer  falls, 
convulsions  occur,  followed,  occasionally, 
by  all  the  symptoms  of  cerebral  haemor- 
rhage, barring  the  hemiplegia,  but  end- 
ing with  cardiac  failure. 

In  the  majority  of  cases,  however,  this 
stage  is  hot  soon  reached.  Besides  the 
first  symptoms  outlined,  there  is  marked 
flushing  of  the  face,  which  may  extend 
to  cyanosis;  the  breathing  is  stertorous; 
there  is  marked  delirium;   nausea  and 


SYMPTOMS.  125 

vomiting  or,  rather,  retching,  and  the 
tongue  is  coated.  In  these  cases  the 
temperature  may  also  be  subnormal  at 
first,  but  it  usually  rises  until  it  some- 
times reaches  115°,  116°,  and  even 
higher. 

In  moderate  cases  the  temperature 
gradually  falls  and  in  three  or  four  days 
the  patient  is  able  to  go  about.  He  is, 
however,  very  apt  to  suffer  from  either 
or  many  of  the  sequelae  already  enumer- 
ated. 

Thermic  Fever  or  Hyperpyrexia. — ■ 
This  is  an  aggravated  form  of  the  pre- 
ceding and  is  not  infrequently  witnessed. 
It  is  characterized  by  excessively  high 
temperature — sometimes  115°,  116°,  and 
even  117.8°  F.,  as  in  the  case  observed  by 
Lambert.  This  means  death,  preceded 
by  intense  dyspnoea,  asphyxia,  and  coma 
in  the  majority  of  cases,  but  by  no  means 
in  all — under  proper  treatment. 

In  a  considerable  proportion  of  cases 
there  are  preliminary  symptoms  which, 
if  accepted  as  warning,  might  prevent 
the  development  of  the  more  dangerous 
features — nausea,  cramps,  progressively 
increasing  weakness,  vertigo,  blurred 
vision,  intense  headache,  and  cessation 
of  the  perspiration.  If  these  symptoms 
do  not  cause  the  patient  to  realize  that 
he  is  in  danger,  and  to  repair  to  a  cooler 
spot — the  active  symptoms  of  thermic 
fever  appear.  The  skin,  from  dry,  be- 
comes flushed,  red,  and  burning;  it  may 
finally  assume  a  bluish  tinge,  while  the 
mucous  membranes  become  markedly 
cyanotic. 

A  thermometer  left  in  situ  would  in- 
dicate that  the  temperature  is  steadily 
rising,  and  though  perhaps  subnormal  at 
first,  reaching  down  as  low  as  95°,  it 
may  reach  the  temperature  already  men- 
tioned. The  pulse  follows  the  tempera- 
ture, and  is  at  first  full,  bounding,  and 
non-compressible,  then  becomes  rapid; 


126 


INSOLATION.    DIAGNOSIS.  ETIOLOGY. 


the  number  of  respirations  also  follows 
suit,  varying  from  20  to  60  per  minute. 
The  eyes  are  watery  and  fixed,  and  the 
pupil  is  contracted. 

Clonic  spasms,  alternating  with  rigid- 
ity, are  often  observed.  There  is  moan- 
ing, delirium,  and  jactitation,  uncon- 
sciousness usually  accompanying  these 
symptoms.  The  urine  and  faeces  are 
passed  involuntarily, — though  the  secre- 
tions are  sometimes  totally  suppressed, 
— and  exacerbations  of  dyspnoea,  notice- 
able from  the  start,  gradually  assume  the 
state  of  asphyxia,  followed  by  death. 

A  fatal  issue  does  not  always  follow, 
however;  and  the  use  of  appropriate 
means,  especially  the  cold  bath,  often 
saves  patients  whose  temperature  has 
reached  extraordinary  limits. 

Case  of  "electric  sun-stroke"  observed. 
The  patient  had  been  engaged  some 
twenty  minutes  in  adjusting  the  screw 
which  separates  the  carbon  points  of  an 
arc-lamp,  his  face  being  held  some  15  to 
20  inches  or  more  from  the  arc,  and  had 
neither  covered  his  eyes  with  smoked 
glasses  nor  taken  any  precaution  against 
radiation.  The  current  was  12  to  14  am- 
peres, with  a  potential  of  44  volts,  and 
the  lamp  had  an  illuminating  power  of 
about  200  Carcel  burners.  Two  hours 
and  a  half  later  the  man  supped  with 
good  appetite,  and  three  hours  after  this 
went  to  bed  and  slept  soundly,  as  usual. 
About  midnight  he  was  awakened  by 
feelings  of  insupportable  pain  and  burn- 
ing in  the  face,  and  especially  the  eyes. 
He  was  unable  to  see,  covered  his  eyes, 
and  complained  of  great  scorching,  which 
was  aggravated  by  the  least  access  of 
light.  The  lids  and  conjunctivae  were 
red  and  swelled,  with  muco  purulent  dis- 
charge. With  pain  he  distinguished  be- 
tween light  and  darkness,  but  could  not 
distinguish  objects.  The  entire  face  was 
reddened,  especially  around  the  eyes. 
Recovery  took  place  under  the  following 
treatment:  Belladonna  ointment  around 
t lie  eyes  and  to  the  lids;  cold  compresses 
to  the  eyes;  occlusion;  hot  foot-baths; 
saline  washes,  with,  later,  the  addition  I 


of  Van  Swieten's  solution.  Prat  (Ar- 
chives de  MM.  Navale,  Dec,  '88). 

Diagnosis. — The  special  conditions  at- 
tending these  cases  and  the  character  of 
the  symptoms  render  diagnosis  easy  in 
almost  all  cases. 

Acute  Alcoholism.  —  In  this  the 
odor  of  alcohol  and  the  previous  history 
of  the  case  render  diagnosis  easy. 

Cerebral  Hemorrhage.  —  This  is 
probably  the  disorder  for  which  insola- 
tion is  differentiated  with  some  diffi- 
culty. The  absence  of  hemiplegia  is  con- 
sidered as  reliable  sign  by  Flint. 

Three  types  of  sun-stroke  specified. 
The  cerebro-spinal,  characterized  by 
symptoms  of  intense  congestion — by  in- 
jection of  the  face  and  conjunctiva,  by 
stertor,  coma,  and  convulsions;  the  syn- 
copal, or  cardiac,  type,  made  manifest  by 
pallor  of  face  and  profuse  perspiration, 
death  taking  place  by  arrest  of  the 
heart;  and  the  pulmonary  form,  in 
which,  in  addition  to  some  of  the  symp- 
toms pertaining  to  the  other  two  there 
are  anxiety,  dyspnoea,  and  asphyxia. 
Sun-stroke  usually  arises  under  condi- 
tions of  mental  or  physical  overactivity 
in  conjunction  with  undue  exposure  to 
heat  and  a  suppression  of  the  secretions, 
the  disease  being  dependent  upon  reten- 
tion, in  the  system,  of  toxic  products  of 
retrograde  metamorphosis.  Martin  ( La 
Sem.  Med.,  Sept.  16,  '91). 

Etiology.- — Excessive  heat  in  any  form 
is  usually  considered  as  the  main  factor 
in  the  production  of  insolation.  It  may 
not  only  occur  in  the  street,  but  also  in 
a  boiler-room,  a  laundry,  etc.,  showing 
that  heat  is  the  predominant  factor. 
Heat-exhaustion  may  be  brought  about 
by  excessive  exertion  under  unfavorable 
conditions,  while  sun-stroke  is  due  to 
excessive  heat  and  occurs  during  the 
hottest  season  of  the  year.  The  latter 
exhibits  remarkable  endemic  characters, 
in  that  it  is  extremely  prevalent  in  one 
locality,  in  another  is  totally  absent, 
though  the  region  may  be  quite  adjacent 


INSOLATION.    ETIOLOGY.  PATHOLOGY. 


127 


and  under  precisely  similar  climatic 
influences;  again,  its  ravages  in  differ- 
ent years  vary  immensely  and  quite  ir- 
respective of  heat.  (Sambon.) 

Exercise  strongly  favors  production  of 
heat-stroke.  Excessive  temperature  acts 
directly  on  the  nervous  system  and  not 
by  inducing  autointoxication  or  coagula- 
tion of  muscle-fibre.  Laveran  (Bull,  de 
l'Acad.  de  MeU  de  Paris,  Nov.  27,  '94). 

Literature  of  '96-'97-'98. 

Insolation  is  due,  not  to  discrete  local 
lesions,  but  rather  to  some  direct  effect 
on  the  brain  as  a  whole.  Jackson  (Bos- 
ton Med.  and  Surg.  Jour.,  Feb.  4,  '97). 

According  to  Phillips,  meteorological 
conditions  predispose  to  sun-stroke,  and 
these  involve  high  temperature,  relative 
humidity,  wind,  and  climatological  char- 
acteristics, as  well  as  the  direct  rays  of 
the  sun.  The  attack  is  no  more  depend- 
ent on  high  temperature  and  direct  in- 
solation, he  thinks,  than  it  is  on  low 
relative  humidity. 

The  reduction  of  physical  resistance 
to  the  action  of  heat  upon  the  nerve- 
centers  and  a  secondary  disturbance  of 
metabolism  probably  at  the  bottom  of 
these  cases.  Thus  fatigue, — mental  and 
physical, — insufficient  food,  unsanitary 
surroundings,  and  worriment  are  all 
noted  as  predisposing  factors.  Alcohol- 
ism is  particularly  active  in  this  respect. 

Literature  of  '96-'97-'98. 

The  colonial  governments  of  Australia 
having  asked  the  medical  board  to  issue 
appropriate  instructions  as  to  prophy- 
laxis from  sun-stroke,  the  fact  was 
elicited  that,  of  all  predisposing  causes, 
undue  indulgence  in  intoxicating  liquor 
is  the  most  common  and  the  most  danger- 
ous. Further,  that  during  the  attack  it 
is  dangerous  to  employ  intoxicants  as  a 
remedy.  Editorial  (Brit.  Med.  Jour., 
June  20,  '90). 

Clinical  and  pathological  study  of  805 


cases  in  which  the  main  factor  was 
shown  to  be  an  autointoxication,  with 
heat  ?s  a  contributing  cause.  Lambert 
and  Van  Gieson  (Medical  Record,  July 
4,  '97). 

Of  465  cases  whose  histories  were 
known  out  of  a  total  of  841  cases,  30  per 
cent,  were  alcoholic,  50  per  cent,  moder- 
ate drinkers,  and  20  per  cent,  teetotalers; 
while  of  70  deaths,  60  per  cent,  occurred 
in  alcoholic  patients,  30  per  cent,  in 
moderate  drinkers,  and  only  10  per  cent, 
in  teetotalers.  Phillips  (Inter.  Med. 
Mag.,  Aug.,  '97). 

Males  are  more  frequently  affected 
than  females,  and  children — though  less 
frequently  attacked — are  not  free  from 
the  disorder,  especially  when  the  head  is 
exposed  to  sun-rays. 

Three  cases  of  thermic  fever  in  infants, 
each  about  one  year  old.  The  cases  de- 
veloped during  the  heated  term,  amid 
the  most  unfavorable  surroundings. 
Each  presented  vomiting,  diarrhoea,  high 
temperature,  and  symptoms  of  profound 
depression.  The  cold  wet-pack  was  used 
in  treatment,  with  most  successful  re- 
sults.  Illoway  (Med.  News,  Aug.  8,  '92). 

Literature  of  '96-'97-'98. 

Convulsions  and  even  death  caused  by 
allowing  children  to  walk  about  in  the 
water  at  the  sea-shore  with  their  clothes 
tucked  up,  their  feet  chilled,  and  their 
heads  exposed  to  the  blazing  sun.  Whit- 
field (Brit.  Med.  Jour.,  Aug.  8,  '96). 

The  majority  of  cases  occur  in  the 
afternoon,  though  cases  are  not  infre- 
quently observed  at  night,  especially  in 
poorly-ventilated  quarters.  In  stoke- 
holes, boiler-rooms,  sugar-refineries,  etc., 
where  the  heat  is  intense,  heat-strokes 
may  occur  at  any  time. 

Pathology. — After  a  study  of  eight 
hundred  and  five  cases  of  insolation, 
Lambert  and  Van  Gieson  found  that 
heat  alone  is  not  sufficient  to  explain  all 
the  clinical  and  pathological  observa- 
tions. The  prodromal  symptoms  of  sun- 
stroke are  those  of  acute  functional  dis- 


128 


INSOLATION.    PATHOLOGY.  TREATMENT. 


turbance,  while  the  later  symptoms, 
much  more  serious,  point  to  grave 
changes  in  the  blood  and  in  all  the 
nerve-centres,  especially  those  of  the 
latter  which  control  the  thermic  mech- 
anism of  the  body. 

Van  Gieson  examined  the  brain  and 
cord  in  several  of  Lambert's  fatal  cases, 
and  found  universal  exhibition  of  acute 
degeneration  of  the  neurons  of  the  whole 
neural  axis.  In  the  cerebral  cortex  and 
cerebellum  the  cells  showed  the  same 
degenerated  changes;  the  cells  of  the 
spinal  cord  were  not  so  extensively 
involved.  The  toxic  agency  of  the 
symptoms  of  insolation  seem  to  be 
shown  by  the  changes  found  in  the  gan- 
glion-cells. They  were,  in  every  way, 
similar  to  those  produced  by  a  number 
of  other  poisons,  such  as  by  alcohol,  lead, 
etc.,  and  by  bacterial  products. 

The  experiments  by  Vallin  would 
tend  to  show  that  coagulation  of  the 
albuminoid  bodies  occurs.  The  toxaemia 
would  thus  occur  as  a  result  of  arrested 
metabolism.  The  blood  is  dark,  though 
fluid,  and  the  corpuscles  are  crenated. 
In  the  hyperpyrexial  form  leucocytosis 
and  degeneration  of  the  red  corpuscles 
may  also  be  noted.  Extravasations  in 
the  peripheral  tissues  are  often  found, 
and  the  body  undergoes  rapid  putrefac- 
tion. 

According  to  de  Santi,  insolation  is  in 
all  cases  characterized,  from  a  patholog- 
ical point  of  view,  by  arrest  of  the  heart, 
but  dependent  on  different  causes. 
These  may  be  classified  as  arising  from 
intoxication  by  the  products  of  muscular 
effort;  from  asphyxia;  from  a  malarial 
infection  called  into  activity  by  fatigue 
or  heat.  In  the  first  form,  that  of  in- 
toxication by  the  products  of  muscular 
exertion,  the  victims  are  chiefly  among 
soldiers  unaccustomed  to  the  fatigue  of 
a  march.    The  attacks  occur  when  the 


temperature  is  high  and  the  air  is  calm 
and  humid;  so  that  the  cutaneous  evapo- 
ration is  small. 

Literature  of  '96-'97-'98. 

The  following  is  a  description  of  the 
micro-organism  found  in  the  blood  of 
patients  suffering  from  heat-apoplexy 
and  regarded  as  the  specific  cause  of  that 
disease.  It  is  linear,  incurved,  and 
slightly  constricted  in  the  middle. 
Viewed  in  the  blood,  it  is  from  2  to  2.5 
microns  long,  and  0.5  micron  thick;  in 
cultures  it  is  somewhat  larger.  It  pre- 
sents filaments,  is  slightly  motile,  but 
possesses  no  cilia,  stains  easily  with  ani- 
line colors,  but  not  by  Gram's  method. 
There  are  free  spores  in  the  cultures  as 
well  as  in  the  rods.  It  is  aerobic,  does 
not  cause  fermentation  in  sugars,  and 
does  not  give  rise  to  indol.  It  grows 
between  30°  and  37°  C,  but  is  instantly 
killed  by  a  moist  heat  of  70°  to  75°  C. 
Cagicol  and  Lapierre  (Montreal  Clinique. 
Apr.,  '98). 

Treatment. — Hydrotherapy  and  skilled 
and  careful  nursing  seem  to  be  the  chief 
factor,  in  treatment  of  insolation;  fre- 
quent recording  of  the  temperature  en- 
abling the  baths  to  be  given  at  the  earli- 
est and,  therefore,  most  effectual  time; 
the  use  of  the  ice  tub-bath,  with  constant 
and  general  friction  of  the  entire  sur- 
face, thus  reducing  the  temperature  in 
the  shortest  possible  time,  and  being 
stimulating  rather  than  depressing;  the 
use  of  the  same  bath  for  all  severe  sec- 
ondary elevations  of  temperature,  and 
for  the  minor  elevations  sponge-baths  of 
ice-water  or  of  water  at  from  70°  to  80° 
F.,  depending  upon  the  individual  case; 
and  the  repetition  of  these  baths  when- 
ever the  temperature  is  high  enough  to 
make  them  seem  advisable.  All  other 
means  have  seemed  entirely  inadequate 
to  N.  R.  Norton. 

At  St.  Vincent's  Hospital.  New  York 
City,  the  following  method  of  treatment 
of  insolation  has  given  good  results.  It 


INSOLATION. 

is  given  here  as  detailed  by  G-.  F.  Chand- 
ler, because  it  seems  most  in  accord  with 
modern  views  as  to  the  pathogenesis  of 
insolation.  The  ambulances  are  well 
supplied  with  ice,  which  is  kept  about 
the  patient's  head  from  the  moment  he 
is  picked  up  until  he  enters  the  hospital. 

Upon  admission  the  patient  is  im- 
mediately stripped.  His  temperature, 
per  rectum,  is  taken  as  he  is  being  placed 
upon  a  raised  stretcher  or  table. 

The  body  of  the  patient  is  covered 
with  a  sheet,  upon  which  are  placed 
small  pieces  of  ice.  Large  quantities  are 
laid  closely  about  the  head.  Ice-water 
from  dippers,  at  a  distance  of  from  five 
to  ten  feet,  are  dashed  with  force  upon 
the  patient.  This  is  continued  about 
thirty  or  forty  minutes. 

The  most  efficacious  stimulant,  and 
one  which  has  served  to  arouse  when 
everything  else  has  failed,  was  the  pour- 
ing, from  an  elevation,  of  a  fine  stream 
of  ice-water  upon  the  forehead.  As  this 
treatment  is  very  radical,  it  is  continued 
for  only  one  or  two  minutes  at  a  time. 
In  severe  cases  it  is  repeated  several 
times,  unless  consciousness  returns. 

While  this  is  going  on,  each  patient, 
with  very  few  exceptions,  is  given  hypo- 
dermically  40  minims  of  the  tincture  of 
digitalis  at  one  dose.  Exception  is  in  the 
case  of  the  plethoric  patients  with  great 
tension  in  the  arteries.  Upon  such  pa- 
tients venesection  is  practiced,  and  later 
tincture  of  digitalis  is  given  in  smaller 
doses. 

The  temperature  is  carefully  watched, 
and  when,  after  hyperpyrexia  it  reaches 
104°  P.,  the  patient  is  laid  in  a  bed, 
covered  with  blankets,  and  hot  bottles 
are  placed  about  him. 

When  the  temperature  is  reduced  to 
99°  or  100°  F.  by  bath,  as  is  usually 
practiced,  clinical  history  shows  that  it 
nearly  always  becomes  subnormal — even 

4—9 


TREATMENT.  139 

falling  at  times  as  low  as  91°  F. — and 
leaves  the  patient  in  collapse.  When  the 
temperature  is  only  reduced  to  104°  F. 
it  will,  in  most  cases,  continue  downward 
of  its  own  accord. 

Strychnine  is  never  given.  It  has 
proved  upon  trial  to  cause  convulsions 
or  make  them  more  violent.  Convul- 
sions are  treated  by  chloroform. 

When  the  secondary  rise  of  tempera- 
ture occurs,  a  sheet,  wrung  from  ice- 
water,  is  spread  over  the  patient,  and 
kept  wet  until  the  temperature  became 
normal.  In  some  of  the  cases,  where  the 
secondary  rise  is  very  rapid,  the  entire 
ice-and-water  treatment  is  repeated  sev- 
eral times,  or  until  the  temperature  re- 
mains normal.  An  ice-cap  is  kept  upon 
the  head  from  the  time  the  temperature 
becomes  normal  until  the  patient  is  dis- 
missed. This  has  been  found  of  the 
utmost  value. 

In  cases  of  prolonged  unconsciousness 
patients  are  nourished  and  stimulated  by 
means  of  the  stomach-tube. 

In  extreme  cases  hypodermics  of 
whisky  are  used. 

As  death  seems  the  result  of  respira- 
tory paralysis,  artificial  respiration  is 
kept  up  for  long  periods  of  time — often 
half  an  hour  or  more.  Surprising  re- 
sults are  sometimes  obtained. 

The  after-treatment  consists  of  light 
diet,  stimulants,  fresh  air,  the  ice-cap, 
and  sudorifics,  such  as  ammonia — prefer- 
ably the  spirit  of  Mindererus — in  large 
doses. 

Preference  expressed  for  the  wet  pack 
over  the  cold  hath  in  the  treatment  of 
heat-stroke.  The  Avet  pack  does  not  pro- 
duce so  rapid  a  depression  of  the  tem- 
perature; hut,  on  the  other  hand,  it  is 
not  followed  by  a  secondary  elevation. 
A  large  muslin  sheet  is  wrung  out  of 
cold  water;  the  patient  wrapped  in  the 
sheet,  placed  in  bed,  and  covered  with  a 
blanket.  As  soon  as  the  sheet  becomes 
warm  it  is  removed  and  replaced  by  an- 


130 


INSOLATION.  TREATMENT. 


other  that  had  meanwhile  been  cooling 
in  the  water.  This  procedure  is  con- 
tinued until  the  temperature  reaches  the 
normal.  Illoway  (Med.  News,  Aug.  8, 
'91). 

The  only  method  by  which  excessive 
fever  can  be  controlled  is  the  cold  bath 
in  the  most  active  form;  same  active 
friction  of  the  skin  necessary  as  is  em- 
ployed in  the  Brand  treatment,  bringing 
hot  blood  from  centre  of  the  body  to  the 
periphery.  Still  colder  application  to  the 
head  to  prevent  fatal  cerebral  congestion. 
Equally  important  is  venesection,  which 
should  be  copious,  particularly  indicated 
in  cases  in  which  there  is  much  cyanosis 
or  convulsions.  Secondary  and  tertiary 
rises  of  temperature  frequently  occur, 
suddenly  shoot  up,  remaining  high  per- 
sistently. In  severe  headache  during 
convalescence,  venesection  of  greatest 
value;  drugs  tending  to  produce  cere- 
bral congestion,  such  as  quinine,  to  be 
avoided.    (Ther.  Gaz.,  '95.) 

During  convalescence,  if  pulse  bound- 
ing, veratrum  viride  and  bromide  of 
sodium  useful;  if  pulse  weak,  ergot. 
Counter-irritation  to  the  nape  of  the 
neck  where  evidences  of  meningeal  irri- 
tability exist.  If  surface  of  the  body  is 
very  cold,  high  injections  of  cold  water 
into  the  colon,  reducing  heat  and  driving 
congested  excess  of  blood  to  the  surface. 
If  heat-exhaustion  occurs  in  which  there 
is  an  unusual  fall  in  bodily  temperature, 
hot  injections  or  baths.  E.  C.  M.  Page 
(St.  Louis  Clinique,  June,  '95). 

Literature  of  '96-'97-'98. 

Ice-baths  and  the  ice-cap  resorted  to, 
but  antipyrine  employed  to  keep  down 
temperature.  Smyth  (Brit.  Med.  Jour., 
Jan.  9,  '97). 

The  ice-pack  and  ice-cap  recommended, 
and  ice- water  dashed  with  force  from 
dippers  at  distances  of  from  eight  to  ten  | 
feet  for  thirty  or  forty  minutes  if  neces- 
sary. The  most  efficacious  stimulant, 
though  it  can  be  applied  only  one  or 
two  minutes  at  a  time,  is  a  fine  stream 
of  ice-water  poured  from  an  elevation 
upon  the  forehead.  Finally,  most  pa- 
tients are  given  subcutaneously  40 
minims  of  digitalis  at  a  dose,  unless  the 
sufferer  is  very  plethoric,  in  which  case 


venesection  is  practiced,  and  the  fox- 
glove given  later  on  in  smaller  doses. 
O'Dwyer  (N.  Y.  Med.  Jour.,  June  5,  '97). 

Great  relief  is  obtained  in  cases  of 
heat-exhaustion  from  the  application  of 
cold  over  the  spine.  In  sun-stroke  the 
cold  bath,  rubbing  with  ice,  blistering, 
shaving  the  head,  and  the  use  of  anti- 
pyrine is  advocated;  although  these 
measures  cannot  compare,  in  the  writer's 
estimation,  with  the  effects  of  heat  ap- 
plied over  the  last  four  cervical  and  first 
four  dorsal  sympathetic  ganglia.  The 
application  of  heat  to  this  region  and  of 
cold  to  the  head,  and  also  the  inhalation 
of  oxygen,  have  been  followed  in  his 
practice  by  the  best  results.  Kinnear 
(Med.  Rec,  Aug.  21,  '97). 

In  thermic  fever  in  infants  the  ice- 
bath  condemned.  In  the  milder  form 
sponging  the  body  with  hydrant-water 
and  the  administration  of  more  water 
internally  is  all  that  is  required.  In  the 
severe  forms  a  bath,  the  temperature  of 
which  is  not  below  60°  F.,  may  be  used; 
at  the  same  time  friction  should  be  vigor- 
ously applied  to  keep  the  peripheral  ar- 
terioles dilated.  Stimulants  may  be 
given  as  required.  In  the  hyperpyrexial 
forms  it  is  well  to  make  the  skin  in- 
tensely red,  as  by  nitroglycerin,  friction 
with  towel  or  hand,  or  a  mustard  bath; 
then  even  sponging  with  hydrant-water 
will  rapidly  produce  the  desired  result. 
Spraying  cold  water  on  the  patient  has 
been  found  to  be  the  most  effective  treat- 
ment. The  water  should  not  be  too  cold. 
For  convulsions  and  tonic  spasms  chloro- 
form is  important.  Free  perspiration 
should  be  induced  as  soon  as  possible. 
Diuretics  act  well  by  assisting  the  elimi- 
nation of  waste-products.  Nnx  vomica 
should  not  be  administered,  as  it  may 
only  be  synergist  to  the  toxin.  Water 
should  be  given  as  soon  as  possible  and 
freely  administered  until  convalescence. 
John  Zahorsky  (Pediatrics.  No.  4.  D8). 

In  the  Indian  territorial  service,  when 
sun-stroke  occurs  in  the  open,  the  sub- 
ject is  at  once  removed  to  a  cool  and 
shady  place,  placed  in  a  recumbent  posi- 
tion, with  the  head  slightly  elevated,  to 
which  cold  applications  are  made.  The 
chest  and  shoulders  are  stripped  and 
cold-douched.     Then  hypodermic  injee- 


INTERNAL  EAR  DISORDERS.  SYMPTOMS. 


131 


tions  of  the  following  are  made  in  differ- 
ent places  about  the  shoulders:  — 
I£  Quin.  sulph.,  gr.  5. 

Acid,  sulph.  dilut.,  m.  5. 
Aquae,  m.  50. 
M.  ft.  liquor. 

Should  the  heart's  action  be  weak,  the 
following  is  used,  hypodermically: — 
R-  Strychninse  sulph.,  gr.  1. 

Aquas,  m.  200. 
M.  ft.  liquor. 

Sig.:  Inject  5  minims  (equal  to  V40 
grain)  p.  r.  n.  C.  Fitz-Henry  Campbell 
(Med.  World,  Aug.,  '98). 

A  watery  solution  of  antipyrine  (1  to 
2)  should  be  carried  in  the  pocket  for 
instant  use  when  there  is  danger  of  en- 
countering cases  of  sun-stroke,  and  as 
soon  as  the  patient  is  seen  20  minims 
should  be  administered  hypodermically. 
Lewis  (Phila.  Med.  and  Surg.  Reporter, 
July,  '98). 

INTERMITTENT  FEVER.  See  Ma- 
laria. 

INTERNAL  EAR,  DISORDERS  OF. — 

The  percipient  apparatus  of  the  ear  is 
relatively  rarely  affected  and  furnishes 
but  2  to  10  per  cent,  of  the  cases  in  the 
statistical  tables, — the  larger  figure  em- 
bracing apparently  every  case  which 
gives  evidence  of  nerve-involvement, 
however  secondary  in  fact  and  impor- 
tance to  tympanic  trouble.  It  comprises 
the  congenital  defects  as  well  as  the  cen- 
tral lesions,  such  as  nerve-atrophy  in 
tabes,  word-deafness  from  cortical  lesion, 
and  many  other  rare  cerebral  affections; 
but  the  group  which  most  concerns  us  in 
this  practical  review  is  made  up  largely 
of  lesions  of  the  labyrinth  due  to  the 
specific  affections,  including  syphilis. 

Tuning-fork  Tests. — The  diagnosis  of 
these  affections  is  largely  from  negative 
evidence,  much  of  it  furnished  by  the 
tuning-fork  tests  of  the  function;  and 
these  had  better  be  here  considered. 

Tuning-forks    can    be  conveniently 


used,  giving  tones  due  to  vibrations  of 
from  50  to  2000  per  second,  and  much 
can  be  learned  by  use  of  A  =  213  v.  s. 
or  C  =  520  v.  s.  alone;  but  it  is  not  best 
to  trust  to  any  one  tone.  The  lower 
forks  must  usually  have  clamps  to 
dampen  the  overtones  (such  can  be  im- 
provised by  slipping  bits  of  rubber-tub- 
ing over  the  ends),  and  in  the  absence  of 
such  will  often  give  the  notes  one  or  two 
octaves  higher  coincidentally  with  the 
fundamental.  For  this  reason  and  for 
its  convenient  duration  of  vibration  I 
prefer  the  A  =  213  v.  s.,  of  medium  size, 
more  often  found  in  the  shops.  Such  a 
fork,  struck  upon  some  rather  soft  sur- 
face by  falling  its  own  length,  should 
generally  be  heard  some  90  seconds 
through  the  air  when  held  before  the 
ear;  while  with  its  handle  resting  upon 
the  mastoid  or  other  portion  of  the  skull 
or  face  it  should  be  audible  slightly  less 
than  half  as  long.  It  should  be  heard 
equally  in  each  ear  from  points  in  the 
middle  line  of  the  head;  and  the  sound- 
waves should  escape  from  each  canal,  as 
can  be  heard  through  the  auscultation- 
tube.  Stopping  the  canal  with  the  finger 
should  increase  the  sound  in  the  closed 
ear  to  a  degree  that  extinguishes  its  per- 
ception in  the  other  and  makes  the  sound 
again  audible  by  bone-conduction  after  it 
has  been  lost  normally.  Low  tones  are 
heard  better  relatively  by  bone;  high 
tones  by  air;  so  high-pitched  forks  should 
have  long  handles  if  their  use  on  the 
mastoid  is  to  be  free  from  possible  fal- 
lacy. Low-toned  forks  should  be  lightly 
struck  to  test  bone-conduction,  lest  their 
vibration  on  the  head  should  be  oppres- 
sively loud. 

If  we  place  the  vibrating  A-fork  on 
one  mastoid  it  should  be  heard  for  some 
40  seconds,  as  stated,  and  for  some  50 
more  when  transferred  to  the  front  of 
the  canal;  and  each  other  fork  has  its 


132 


INTERNAL  EAR  DISORDERS.  SYMPTOMS. 


fairly-definite  proportion  for  a  normal 
ear,  equal  on  the  two  sides.  But  in  deaf 
ears  the  finding  will  be  different  and  dis- 
crepant perhaps  on  the  two  sides.  Lesion 
of  the  conducting-apparatus  will  impede 
alike  the  entrance  of  sound-waves  by  air 
and  their  escape  from  the  tympanum 
when  awakened  there  through  bone-con- 
duction. Hearing  by  air-conduction  will 
be  subnormal,  by  bone-conduction  it  will 
be  exaggerated;  the  proportion  changing 
from  90:40  to  perhaps  30:50,  bone-con- 
duction preponderating.  This  is  Einne's 
or  Schwabach's  test, — modified  by  Roosa 
very  practically  by  merely  noting 
whether  it  is  "louder  front?  or  back?" 
as  almost  any  patient  can  rightly  decide. 

If  the  deafness  be  due  to  the  percipient 
apparatus,  the  normal  preponderance  of 
air-conduction  will  continue,  bone-con- 
duction being  relatively  worse,  or,  per- 
haps, totally  lost.  The  proportion  may 
now  be  A.  C.  40:  B.  C.  10.  So,  too,  from 
the  middle  line  of  the  head  the  hearing 
will  be  worse  in  the  worse  internal  ear, 
whereas  if  the  trouble  be  in  the  conduct- 
ing apparatus  the  more  obstructed  ear 
will  be  the  one  hearing  louder  by  bone- 
conduction.    This  is  Weber's  test. 

Gardiner  Brown  modified  Weber's  test 
by  resting  the  tuning-fork  on  the  bridge 
of  the  nose  and  having  the  patient  raise 
his  finger  just  when  he  ceased  to  hear  its 
vibration.  As  this  should  be  exactly  when 
the  vibrations  ceased  to  be  j:elt  by  the 
fingers  of  the  examiner,  a  rough,  but 
practical,  measure  is  gained  (for  each 
ear  if  unequal)  of  the  increase  or  de- 
crease of  the  bone-conduction,  and  the 
result  is  conveniently  stated  as  +  3  sec- 
onds, —  4",  etc. 

Cases  will  frequently  be  met  where 
these  tests  give  uncertain  or  contradic- 
tory results.  Patients  will  give  their 
preconceptions  instead  of  observing  the 
actual  perceptions,  unwilling  to  say  that 


they  hear  by  bone  louder  in  the  ear  which 
they  know  to  be  worse  or  confusing  pal- 
pable vibrations  with  their  weakened  au- 
ditory perceptions.  A  deaf-mute  will 
often  claim  to  hear  the  fork  as  well  rest- 
ing on  the  patella  as  when  on  the  mas- 
toid. Yet  a  little  patience  and  variation 
of  the  tests  will  generally  clear  up  con- 
tradictions. The  high  tones  are  later 
and  in  less  degree  lost  in  tympanic  affec- 
tions, unless  thickening  of  the  drum- 
head shut  out  some  such  sound  tone  as 
the  impure  of  the  watch-tick. 

The  catarrhally  deaf  usually  hear  rela- 
tively or  even  actually  better  in  a  noise, 
—  "paracusis  Willisii";  whereas  those 
with  nerve-deafness  are  made  worse  by 
it.  Very  high  tones,  such  as  given  by 
the  Koenig  rods  or  the  Galton  whistle, 
may  be  inaudible  to  a  diseased  labyrinth 
or  portions  of  the  gamut  may  be  lost, 
while  all  voice-tones,  as  well  as  much 
deeper  notes,  are  normally  heard.  These 
limitations  must  be  learned  and  borne 
in  mind;  then  the  tuning-fork  tests  will 
generally  be  found  to  lead  to  correct 
diagnosis;  and  the  many  instances  of 
mixed  affection  will  be  noted  as  well  as 
those  which  are  totally  differentiated. 

In  affections  of  the  Eustachian  tube 
and  in  those  of  the  external  aural  ductus, 
the  sound  of  a  vibrating  diapason  is  al- 
ways heard  on  the  shut  or  impaired  side 
stronger  than  on  the  crossed  side.  Tn 
cases  of  disease  of  the  tympanic  cavity 
without  involvement  of  the  acoustic 
nerve  it  is  always  heard  from  the  direct 
side,  though  one  side  is  more  impaired 
than  the  other.  In  cases  of  diseases  of 
the  tympanic  cavity  with  hypenrsthesia 
of  the  acoustic  nerve,  or  in  cases  of  this 
condition  only,  the  sound  is  heard  from 
the  hypenrsthctic  side,  but  stronger  on 
the  crossed  side.  In  cases  of  disease  of 
the  internal  ear  (atony  or  atrophy  of  the 
acoustic  nerve),  with  or  without  impair- 
ment of  the  tympanic  cavity,  the  percep- 
tion of  tin1  crossed  sound  is  abolished, 
while  sometimes  the  direct   sound  con- 


INTERNAL  EAR  DISORDERS. 


GENERAL  DIAGNOSIS. 


133 


tinues  (although  very  weak).  Masini 
(Bullettino  delle  Malattie  della  Gola  e 
del  Naso,  July,  '88). 

Literature  of  '96-'97-'98. 

Ability  to  hear  the  voice  at  a  distance 
proportionately  greater  than  the  distance 
at  which  the  sounds  of  a  clock  can  be 
heard  is  a  symptom  of  disease  of  the 
cochlea  or  of  the  acoustic  nerve.  Four 
principal, types  of  cases  may  show  a  dis- 
proportionate relationship  in  the  ability 
to  hear  these  two  classes  of  sound:  1. 
Aphonic  voice  and  clock  with  strong  tick 
heard  at  about  the  same  distance, — a  rare 
type  appearing  in  slight  affections  of 
the  sound-conducting  apparatus.  2.  The 
voice  heard  about  three  times  farther 
than  the  clock, — a  more  frequent  type, 
found  in  nerve  affections  of  the  sound- 
conducting  apparatus.  3.  The  voice  heard 
at  a  still  greater  distance, — fifty  times 
farther  than  the  clock,  as  in  disease  of 
the  inner  ear  in  young  subjects.  4.  The 
clock  heard  farther,  sometimes  ten  times 
farther  than  the  voice, — a  rare  type  seen 
only  in  hysterical  conditions  and  quite 
characteristic  of  this  affection.  Gra- 
denigo  (Annual,  '96). 

Diagnosticated  in  the  manner  outlined 
above  there  will  be  a  small,  but  impor- 
tant, group  in  which  there  has  been  a 
small-cell  infiltration  of  the  labyrinth 
as  the  result  of  syphilis,  acquired  or  in- 
herited; of  cerebro-spinal  meningitis,  or 
typhoid,  or  other  fevers.  The  onset  of 
the  deafness  may  be  sudden,  usually 
without  vertigo,  or  it  may  be  stealthy 
and  gradual.  Acoustic  hyperesthesia 
may  precede  it,  and  the  condition  may 
be  very  unequal  on  the  two  sides.  In 
children,  who  are  its  more  frequent  vic- 
tims, it  is  generally  only  noted  that  they 
do  not  hear  or  that  they  are  not  talking 
as  they  should.  Convulsions  without  de- 
fined or  protracted  illness  may  be  re- 
ported as  the  starting-point,  or  trauma 
with  loss  of  consciousness.  The  deaf- 
ness following  mumps  may  belong  in 
11:  is  category,  but  generally  seems  rather 
an  acoustic  paralysis. 


Autopsies  in  cases  of  cerebro-spinal 
fever  where  there  had  developed  deafness 
intra  vitam,  which  revealed  destructive 
tissue-changes  in  the  internal  ear.  The 
processes  were  suppuration  and  necrosis. 
The  probable  cause  is  a  direct  action  of 
the  morbid  virus  upon  the  capillaries  of 
the  periosteum, — and  pre-eminently  in 
the  semicircular  canals, — producing  vas- 
cular stasis  and  thrombosis  in  this  mem- 
brane, with  consequent  necrosis  of  the 
structures  thereto  attached.  Stein- 
brugge  (Archives  of  Otology,  vol.  xvii, 
p.  51,  '88). 

Two  cases  of  total  loss  of  hearing  in 
both  ears  consequent  upon  mumps.  One 
patient  had  suffered  from  purulent  otitis; 
the  other  case  presented  normal  mem- 
branse  tympani.  In  such  cases  the  lesion 
is  located  within  the  labyrinth.  Barr 
( Glasgow  Med.  Jour.,  June,  '89). 

As  a  result  of  scarlatina,  three  differ- 
ent conditions  of  the  aural  mucous  mem- 
brane are  noted:  1.  Great  swelling,  with 
serous  infiltrations  of  the  connective- 
tissue  stroma.  In  such  conditions  the 
exudate  is  purulent  and  tends  to  per- 
foration of  the  drum-head.  2.  Necrosis 
of  swelled  mucous  membrane;  so  that,  in 
many  cases,  the  ossicles  are  denuded  of 
periosteum.  3.  Acute  carious  process 
upon  the  wall  of  the  labyrinth  and  the 
ossicles.  This  condition  soon  leads  to  in- 
flammation of  the  membranous  laby- 
rinth. L.  Katz  (Deutsche  med.-Zeit., 
July  8,  '90). 

Literature  of  '96-'97-'98. 

Deafness,  tinnitus,  and  vertigo  may  be 
caused  by  either  congestion  or  anaemia 
of  the  labyrinth.  The  inhalation  of  a 
few  drops  of  nitrite  of  amyl  will  tempo- 
rarily relieve  these  symptoms  if  they  be 
due  to  ischsemia,  but  will  increase  them 
if  they  be  due  to  congestion.  This  differ- 
entiation of  etiology  will  enable  the 
physician  to  properly  treat  the  disease. 
Lermoyez  (Ann.  des  Mai.  de  l'Oreille, 
July,  '90). 

Apoplectiform  affections  of  the  laby- 
rinth in  two  men  employed  in  submerged 
caissons.  When  the  Eustachian  tube  is 
permeable  the  ear  endures  the  increased 
atmospheric  pressure  in  submarine  cais- 
sons;  when  it  is  not  permeable,  the  in- 


INTERNAL  EAR  DISORDERS.  SYPHILIS. 


ward  pressure  of  the  membrana  produces 
congestion  of  the  drum-cavity  and  finally 
of  the  internal  ear.  F.  Alt  (Aust.  Otol. 
Soc,  June,  '96;  Ann.  des  Mai.  de  l'Ore- 
ille,  Jan.,  '97). 

Syphilis. 

The  stigmata  of  inherited  syphilis  are 
to  be  sought  in  the  typical  facies;  with 
it  exaggerated  naso-labial  lines,  the  high- 
vaulted  palate,  wide-spaced  and  pegged 
incisor  teeth,  only  sometimes  notched, 
the  clouded  cornea?  or  nodes  upon  the 
shin  or  other  bones.  The  family-history, 
with  miscarriages  and  early  deaths  or 
typical  lesions  in  other  members,  may  be 
our  only  evidence. 

Literature  of  '96-'97-'98. 

Absolute  deafness  cannot  be  merely 
tympanic;  in  such  cases  we  can  con- 
ceive of  no  obstruction  which  could 
totally  prevent  conduction  to  a  sensitive 
labyrinth,  and  must  assume  impairment 
of  this  or  the  centres  beyond.  In  some 
instances  where  the  response  to  tests  is 
uncertain  or  contradictory,  the  presence 
of  Hutchinson  teeth,  interstitial  kera- 
titis, or  other  evidences  of  congenital 
syphilis  may  serve  to  warn  us  of  the 
probability  of  deeper  trouble,  even  if  the 
abnormality  of  the  drum-heads  may  seem 
to  account  for  the  deafness  as  tympanic. 

In  any  case  where  the  patient  seems 
worse  for  inflation,  it  will  be  well  to  re- 
view the  tests  for  suspected  affection  of 
the  internal  ear;  and  unless  explanation 
can  be  found  in  an  overdistended  drum- 
head or  unintentionally  vigorous  use  of 
the  air-douche,  even  negative  findings 
must  put  us  on  our  guard.  B.  A.  Ran- 
dall (Phila.  Polyclinic,  Feb.  8,  '9C). 

Form  of  acute  syphilitic  affection  of 
the  ear,  probably  due  to  an  effusion  into 
the  labyrinth  in  a  previously  normal  ear, 
is  characterized  by  sudden  deafness,  tin- 
nitus, and  vertigo,  coming  on  in  the  late 
secondary  or  early  tertiary  stage  of  sys- 
tematic syphilis.  The  difference  between 
this  form  of  sudden  deafness,  tinnitus, 
and  vertigo,  and  that  due  to  non- 
syphilitic  causes  is  that  the  deafness  is 
not  so  profound  in  the  specific  form. 
The    syphilitic    aural    affection  yields 


promptly  to  a  few  doses  given  hypo- 
dermically  of  pilocarpine  (V8  grain), 
whereas  non-syphilitic  labyrinth  diseases 
are  entirely  unaffected  by  pilocarpine. 
E.  A.  Crockett  (Boston  Med.  and  Surg. 
Jour.,  Feb.  11,  '97). 

Treatment. — Whether  syphilitic  or  not, 
the  same  treatment  "is  indicated.  Ab- 
sorption of  the  infiltration  by  mercurials 
and  iodides  constitutes  our  main  resort. 
In  recent  specific  cases  Politzer's  vigor- 
ous use  of  pilocarpine  has  given  excellent 
results  in  some  cases;  but  the  treatment 
cannot  always  be  borne,  is  inconvenient 
with  its  sweatings,  and  can  hardly  equal 
for  the  ear  or  for  the  general  condition 
the  usual  antisyphilitic  medication. 
Long-standing  cases  offer  little  prospect 
of  benefit,  but  they  have  been  known  to 
gain  beyond  all  expectation;  and  the 
underlying  disease  may  in  itself  demand 
treatment. 

Subcutaneous  injections  of  pilocarpine, 
beginning  with  2  drops  of  a  2-per-cent. 
solution  and  increasing  to  8  drops,  are 
of  great  service  in  all  recent  affections 
of  the  labyrinth.  From  10  to  15  injec- 
tions ought  to  produce  the  result  aimed 
at;  if  not.  the  remedy  is  to  be  aban- 
doned.   Politzer  (Lancet.  Jan.  2,  '91). 

Nitroglycerin  exerts  but  little  influence 
in  disease  of  the  labyrinth  in  hereditary 
syphilis  (where  the  iodide  of  potassium 
yields  better  results).  It  is  of  the  great- 
est utility  in  the  removal  of  hsemorrhagic 
extravasation  or  recently  -  organized 
lymph,  especially  in  acute  processes  in 
the  labyrinth.  Politzer  (Weiner  med. 
Blatter/ No.  4,  '88). 

Literature  of  '96-'97-'9S. 

In  a  case  of  anaemia  of  the  labyrinth 
trinitrin  in  doses  of  Vmo  grain  three 
times  daily  permanently  relieves  the 
deafness,  tinnitus,  and  vertigo.  In  cases 
of  congestion  of  the  labyrinth  an  alter- 
ative or  absorbent  treatment  is  indi- 
cated. Lermoyez  (Ann.  des.  Mai.  de 
l'Oreille.  .Inly.  '96). 

Pilocarpine  gives  the  best  results  in 
syphilitic  diseases  of  the  internal  ear. 


INTERNAL  EAR  DISORDERS. 


MENIERE'S  DISEASE. 


135 


Thomas  J.  Harris  (Manhattan  Eye  and 
Ear  Hosp.  Rep.,  Jan.,  '97). 

Labyrinthine  Effusion  (Meniere's  Dis- 
ease). 

Another  notable  group  includes  the 
cases  of  labyrinthine  effusion  causing 
vertigo  and  deafness,  generally  associated 
with  Meniere's  name.  "The  Meniere 
complex  of  symptoms"  is  now  generally 
spoken  of,  and  some  writers  have  not 
only  differentiated  tympanic  vertigoes, 
but  have  inclined  to  deny  the  reality  of 
"Meniere's  disease."  Yet,  clear-cut  cases 
of  this  affection  do  undoubtedly  occur, 
and  the  influenza  epidemics  caused  not 
a  few  of  them.  The  seizure  is  usually 
apoplectiform,  with  intense  vertigo,  not 
infrequently  severe  nausea  and  marked 
deafness.  Some  cases  note  the  dizziness 
only  on  rising,  but  others  are  almost  as 
distressed  by  it  while  at  absolute  rest  in 
bed.  Whether  the  acoustic  or  the  co- 
ordination areas  of  the  labyrinth  are  the 
seat  of  the  lesion,  both  functions  are  at 
first  profoundly  affected;  but  the  mere 
serous  effusions  can  probably  absorb  com- 
pletely, leaving  no  loss  of  hearing.  As 
the  labyrinth  vertigo  is  usually  an  irrita- 
tive lesion,  disappearing  equally  whether 
resolution  or  destruction  be  the  result, 
it  is  possible  that  all  of  the  profound 
affections  are  exudative  or  hagmorrhagic, 
but  that  we  have  no  means  of  recogniz- 
ing the  destruction  left  in  the  semicir- 
cular canals,  if  the  limited  lesion  is  here. 
Some  cases  of  typical  labyrinthine  apo- 
plexy recover  almost  completely,  but 
with  a  permanent  gap  at  some  part  of  the 
auditory  scale. 

In  gouty  cases  a  train  of  symptoms 
suddenly  arises,  resulting  from  serous 
efl'usion  into  the  labyrinth,  and  giving 
most  of  the  characteristics  of  Meniere's 
disease, — tinnitus  and  deafness,  especially 
for  tones  of  high  pitch,  being  intense. 
The  musical  sense  is  lost.  The  attack 
disappears,  but  recurs  with  ever-shorten- 


ing intervals  of  health,  and  produces 
progressive  impairment  of  hearing.  A 
point  of  differential  diagnosis  between 
this  condition  and  a  simple  catarrhal 
process  is  that,  in  the  latter,  there  exists 
an  inequality  in  hearing  between  the  two 
ears.  In  labyrinth  effusion,  the  conduct- 
ing apparatus  being  unaffected,  the  note 
will  be  heard  as  one  clear  sound.  Alex. 
Ogston  (Med.  Press  and  Circular,  June 
11,  '90). 

In  two  cases  the  patients  presented  all 
the  phases  of  Meniere's  disease,  while  the 
parents  ana  other  members  of  the  family 
suffered  either  from  similar  symptoms  or 
from  nervous  manifestations.  Simon 
(Johns  Hopkins  Hosp.  Bull.,  Sept.,  '93). 

Meniere's  disease  is  relatively  frequent 
in  cases  of  ozsena,  while  middle-ear 
catarrh  with  nasal  disease  has  occurred 
in  many  cases.  Among  constitutional 
dyscrasias  syphilis  is  a  frequent  exciting 
cause  of  labyrinthine  haemorrhage,  while 
many  cases  may  be  traced  to  Bright's 
disease,  atheromatous  arteries,  exertion, 
trauma,  mumps,  etc.  Thomas  Barr 
(Brit.  Med.  Jour.,  Dec.  28,  '95). 

Literature  of  '96-'97-'98. 

The  deafness  resulting  from  an  intense 
extravasation  within  the  labyrinth,  such 
as  occurs  in  Meniere's  disease,  never  dis- 
appears and  is  usually  bilateral.  T.  A. 
Kenefic  (Med.  Rec,  July  25,  '96). 

Treatment.  —  Total  rest,  derivatives, 
and  perhaps  blood-letting  should  be  first 
tried,  followed  by  absorbent  alteratives. 
Charcot's  use  of  heroic  doses  of  quinine 
should  be  a  last  resort,  as  a  means  to 
complete  the  destruction  of  tissues  in- 
capable of  resolution. 

In  treatment  of  Meniere's  disease  re- 
liance placed  upon  quinine,  especially  in 
the  chronic  forms,  and  combined,  usually, 
with  ergotine  in  equal  dose,  namely: 
from  9  to  15  Va  grains  daily.  In  the 
apoplectic  type  of  the  disease  quinine  is 
superfluous,  but  iodide  of  potassium  is  of 
great  use.  Tsakyroglous  (Monatshefte  f. 
Ohrenh.,  Nov.,  '92). 

Three  cases  of  Meniere's  disease  cured 
by  the  administration  daily  of  three 
powders  containing  each  46  grains  of 
bromide  of  potassium,  and  three  pills, — 


136        INTERNAL  EAR  DISORDERS.    OCCUPATION  DEAFNESS.  TINNITUS. 


valerianate  of  iron,  15  V2  grains;  opium, 
4  grains;  extract  and  powder  of  eas- 
cara  sagrada,  q.  s.  ad  pil.  xij.  The  cure 
was  permanent.  Romeo  Mongardi  (An- 
nates des  Mai.  de  l'Oreille,  etc.,  Dec,  '92). 

The  effect  of  quinine,  salicylic  acid, 
and  other  drugs  upon  the  labyrinth  is 
often  misunderstood.  They  certainly 
cause  hyperemia  in  physiological  dose; 
but  probably  here,  as  elsewhere,  in  toxic 
doses  produce  profound  ischsemia,  such 
as  is  seen  in  the  eye  in  quinine-blind- 
ness. Diseased  ears  are  apt  to  be  espe- 
cially susceptible  to  the  tinnitus  and 
other  discomforts  of  these  drugs;  but  it 
is  an  open  question  whether  they  are 
more  prone  to  be  injured  by  them  than 
normal.  Malarial  affections  may  leave 
marked  or  total  deafness  when  no  qui- 
nine has  been  given;  and  many  a  case 
has  unjustly  drawn  blame  upon  the  phy- 
sician because  he  has  given  quinine  when 
his  only  error,  if  any,  has  been  in  giving 
too  little.  Just  as  in  the  tympanic  in- 
flammations, stasis  must  be  overcome  at 
times,  and  quinine  is  often  our  best,  if 
not  the  most  comfortable,  means  to  this 
end.  As  the  prejudice  against  it  is  wide- 
spread, however,  great  caution  must  be 
employed  in  its  use;  even  those  with 
anaemic  tinnitus,  who  find  prompt  relief 
from  its  exhibition,  showing  sometimes 
the  greatest  reluctance  to  take  it. 

Akin,  perhaps,  to  these  cases  are  the 
losses  of  hearing  following  mumps,  diph- 
theria, and  other  acute  affections.  They 
can,  perhaps,  be  best  compared  to  the 
blindness  following  ptomaine-poisoning 
from  sausage  and  such  foods.  There  is 
certainly  microbic  invasion  of  the  laby- 
rinth in  some  of  the  diphtheritic  cases; 
but  these  are  apt  to  show  the  more  usual 
septic  inflammatory  reactions.  Acoustic 
atrophy,  like  that  of  the  optic  nerve, 
generally  calls  for  an  alterative  course  to 
limit  and  repair,  if  possible,  the  ulterior 


lesion,  followed  by  vigorous  strychnine 
stimulation. 

Occupation-deafness. 

Finally,  the  matter  of  "occupation- 
deafness"  demands  our  consideration, 
since  it  offers  a  valuable  field  for  pro- 
phylaxis. "Boilermakers'  deafness"  is 
met  among  workmen  in  many  trades 
where  noise  is  great  and  continuous;  but 
the  riveter  inside  a  boiler  is  naturally 
the  most  prone  to  suffer  with  the  effects 
of  such  concussion  upon  his  acoustic 
apparatus.  Tampons  have  been  em- 
ployed with  slight  palliative  effect;  but 
the  sufferer  had  best  change  his  work  to 
a  safer  one.  Tympanic  affection  may  be 
coincidently  active  and  demand  appro- 
priate treatment,  but  should  not  blind  us 
to  the  deeper  condition.  The  rapid-fire 
automatic  gun  is  likely  to  claim  many 
victims  in  this  way,  just  as  the  dentist's 
electric  hammer  paralyzed  the  nerve- 
supply  of  many  teeth  before  its  dangers 
were  recognized.  So,  too,  the  various 
methods  of  persistent  pneumatic  or 
phono-massage  have  wrought  much  dam- 
age already  and  are  likely  to  find  count- 
less victims  yet,  who  are  misled  by  a 
brief  stimulation  of  the  torpid  nervous 
apparatus  and  press  on  with  the  measure 
until  all  acoustic  reaction  is  exhausted. 

Tinnitus. 

Tinnitus  is  a  symptom  rather  than  an 
affection,  as  to  which  much  remains  to 
be  learned.  Where  it  is  high  pitched 
and  of  long  standing  little  expectation 
of  its  disappearance  should  be  raised;  but 
it  ought  to  be  generally  possible  to  re- 
duce it  to  a  mild  annoyance.  It  is  at 
times  strictly  cerebral:  may  be  due  to 
turbinal  pressure  in  the  nose;  but  is  gen- 
erally of  tympanic  origin  and  can  be 
benefited  by  treatment  of  the  coincident 
deafness.  Yet  it  may  have  no  relation 
to  the  defect  of  hearing,  occurring  when 


INTERNAL  EAR  DISORDERS. 


INTERTRIGO.    SYMPTOMS.  137 


it  is  imthreatened  or  persisting  after  it 
has  been  restored.  General  vascular  con- 
ditions must  be  looked  to  in  the  blowing 
type  of  noises,  and  dietetic  rather  than 
medicinal  measures  resorted  to.  Pneu- 
matic massage,  most  easily  employed 
with  the  finger-tip,  will  often  do  much 
for  its  relief. 

Use  of  Delstanche's  rarefacteur  ad- 
vised in  labyrinthine  disturbance  due  to 
sudden  loud  noises  or  explosions  for  the 
purpose  of  restoring  to  a  normal  position 
the  indriven  tympanic  structures  and 
stapes.  Pilocarpine  is  not  contra-indi- 
cated in  inflammation  of  the  auditory 
nerve  due  to  meningitis,  but,  on  the  con- 
trary, is  to  be  recommended  in  recent 
cases  in  view  of  the  fact  that  the  laby- 
rinth is  usually  implicated.  In  the  use 
of  the  galvanic  current  in  cases  of  nerv- 
ous tinnitis  the  positive  pole  should  be 
applied  to  the  tragus.  When  one  ear 
only  is  being  galvanized  the  current 
should  not  exceed  from  2  to  4  milliam- 
peres,  and  it  is  only  when  the  current  is 
divided  between  the  two  ears,  both  being 
treated  at  the  same  time,  that  it  is  at  all 
advisable  to  double  the  strength  of  the 
current.  Dundas  Grant  (Lancet,  Aug. 
24,  Sept,  14,  '95). 

B.  Alexander  Randall, 

Philadelphia. 

INTERTRIGO. 

Definition. — Intertrigo  is  an  hyper- 
aemic  affection  of  the  skin  characterized 
by  an  erythematous  condition  produced 
upon  contiguous  surfaces,  accompanied 
with  an  exudation  of  sweat  with  macera- 
tion of  the  skin. 

Symptoms. — Intertrigo  is  produced 
th  rough,  closeness  of  contact  between 
two  opposing  surfaces  The  juxtaposi- 
tion may  cause  irritation  whether  as- 
sisted or  not  by  friction.  It  is  an  affec- 
tion of  hot  weather,  but  may  also  occur 
in  the  winter.  Heat  acting  directly  on 
the  subject  and  thus  indirectly  upon  con- 
tiguous areas  assists  in  its  production  and 


extension.  It  occurs  in  regions  such  as 
the  nates,  groins,  axilla?,  the  spaces  be- 
tween and  beneath  the  breasts  in  the 
female  or  in  corpulent  males,  as  well  as 
overlapping  portions  of  the  abdomen,  the 
sulci  of  the  fingers  and  toes  and,  in  fact, 
any  redundant  portion  of  skin. 

At  first  there  is  only  an  erythematous 
blush,  but  this  soon  increases  in  degree 
and  in  extent.  Prolonged  contiguity  may 
lead  to  a  true  traumatic  erythema,  which 
with  the  retained  sweat  causes  macera- 
tion of  the  adjacent  portions  of  skin.  If 
allowed  to  continue,  the  maceration  may 
extend  and  end  in  a  true  inflammatory 
process.  In  infants  intertrigo  is  apt  to 
be  an  annoying  affection,  especially 
when  it  occurs  through  inattention  of 
the  parts  after  micturition  and  defeca- 
tion. Eczema  is  likely  to  supervene  if 
no  attention  be  given.  The  rubbing  is 
also  encountered  after  horseback-riding, 
rubbing  of  tight-fitting  boots  or  clothes, 
etc.  (erythema  paratrimma). 

The  parts  are  hot  and  tender,  if  not 
actually  painful,  and  movement  causes 
a  scraping  sensation.  In  an  unattended 
case  bleeding  may  occur  as  a  result  of  fis- 
sures and  removal  of  the  upper  layers  of 
the  epidermis.  The  parts  emit  a  dis- 
agreeable odor,  and  according  to  Crocker, 
of  London,  stain — but  do  not  stiffen — 
linen:  a  point  which  this  author  adduces 
as  of  diagnostic  value  between  eczema 
and  intertrigo. 

Diagnosis. — The  diagnosis  of  this  con- 
dition is  not  difficult.  The  fact  that 
there  are  two  opposing  surfaces  in  which 
there  is  a  retention  of  sweat,  emitting  a 
disagreeable  odor,  and  causing  macera- 
tion and  Assuring  of  these  surfaces, 
should  be  sufficient  in  most  cases.  Re- 
moval of  the  cause  is  generally  followed 
by  an  early  cessation  of  the  symptoms. 
Eczema  will  persist  for  shorter  or  longer 
periods,  according  to  the  extent  of  sur- 


138 


INTERTRIGO.    ETIOLOGY.  TREATMENT. 


face  involved,  and  not  alone  will  remain 
in  position,  but  will  also  increase,  if  not 
judiciously  treated.    In  the  latter  affec- 
tion there  is  some  degree  of  infiltration 
and  thickening,  which  does  not  occur  in 
erythema  intertrigo  unless  eczema  com- 
plicates the  process.   Congenital  syphilis  | 
may  also  be  confounded  with  this  affec- 
tion, but  the  fact  that  syphilis  extends 
far  beyond  the  borders  of  the  contiguous 
surfaces  will  generally  suffice  to  prevent 
error.    Syphilis  also  produces  a  darker 
discoloration.    An  "erythema  syphilidi-  I 
forme"  is  noted  by  A.  Fournier,  which  j 
begins  as  a  papulo-vesicle  and  resembles  | 
the  vaccine-papule;  but,  as  these  lesions 
are  to  be  found  in  repeated  succession, 
error  is  hardly  possible. 

Etiology. — The  causes  of  intertrigo 
are  manifold.  Warm  weather  or  heat 
produced  by  artificial  means  during  the  J 
winter  season  may  act  as  an  inducing  I 
factor.  Exaggerated  exercise,  rowing, 
running,  horseback-riding,  as  well  as 
sedentary  habits  as  observed  in  clerks 
who  sit  for  long  periods  on  leather-cush- 
ioned stools,  or  persons  who  wear  un- 
suitable undergarments,  and  sweating  at 
contiguous  points  are  known  causes. 
Friction,  with  or  without  moisture,  will 
induce  it.  Secretions — such  as  saliva 
(the  cases,  for  instance,  following  re- 
peated protrusion  of  the  tongue  and  lick- 
ing the  parts),  vaginal  discharges,  un- 
removed  faeces  during  the  existence  of  a 
diarrhoea,  the  dribbling  of  urine  and  the 
complication  of  glycosuria — are  as  many  j 
etiological  factors.  Many  other  condi-  j 
tions  contribute  to  assist  in  its  produc- 
tion and  extension,  such  as  the  milk 
upon  the  garments  of  careless  mothers, 
which,  thus  being  allowed  to  dry,  rough- 
ens and  stiffens  the  dressings;  so  that 
rubbing  is  soon  induced.  In  young  j 
infants  improperly-washed  diapers  are 
also  causative  media. 


Treatment. — As  a  rule,  little  or  no 
treatment  is  required.  Kemoval  of  the 
cause  will  usually  end  in  early  recovery. 
Inattention  to  the  parts  may  allow  the 
case  to  proceed  to  a  high  grade  of  inflam- 
mation. The  first  indication  is  to  re- 
move, by  means  of  some  bland  soap — 
Castile  or  glycerin  soap — and  water,  the 
foreign  elements  acting  as  irritating  fac- 
tors, and  immediately  afterward  dry  with 
a  soft  towel.  An  odor  may  require  the 
addition  of  a  slight  quantity  of  carbolic 
acid  or  thymol.  Bland  dusting-powders 
are  very  useful;  but  if  allowed  to  remain 
and  absorb  the  discharges  they  induce 
an  aggravation.  Boric  acid,  talc,  ful- 
lers' earth,  lycopodium,  or  starch  in  im- 
palpable powder  relieves  both  pain  and 
irritation.  Solutions  are  often  more 
grateful,  but  must  be  applied  almost  con- 
tinuously to  obtain  good  effects.  Boric 
acid  in  saturated  solution  is  one  of  the 
best  agents.  Sulphite  and  hyposulphite 
of  sodium  in  water  in  the  strength 
of  from  1/2  to  1  drachm  to  the  ounce  are 
often  beneficial.  Astringent  washes  give 
excellent  results.  Acetate  of  lead  (3  to 
5  grains  to  the  ounce  of  water),  sulphate 
of  zinc  (1  or  more  grains  to  ounce  of 
water),  acetate  of  zinc  (in  similar  pro- 
portions), bichloride  of  mercury  (1  to  2 
grains  to  1000  parts  of  water),  calomel 
(3  to  5  grains  to  the  ounce  of  lime-water 
— lotto  nigra)  are  all  efficacious.  A  use- 
ful method  is  to  apply  one  of  the  above 
lotions  for  a  period  of  fifteen  minutes, 
then  to  thoroughly  dry  the  parts  by  mop- 
ping them;  and  to  follow  this  by  one  of 
the  dusting-powders.  This  should  be 
carried  out  three  or  more  times  during 
each  half  of  the  twenty-four  hours.  In 
addition  to  the  remedial  measures  the 
parts  must  be  kept  apart  by  means  of 
medicated  lint  or  cotton:  a  procedure 
which  suffices  in  some  of  the  cases  ob- 
served.  In  obstinate  cases  it  may  be  ad- 


INTESTINES.  DUODENITIS. 


SYMPTOMS. 


DUODENUM,  ULCERATION. 


139 


visable  to  place  the  patient  in  bed  to 
keep  the  limbs  apart  until  the  acute 
phase  of  the  trouble  disappears. 

J.  Abbott  Cantkell, 

Philadelphia. 

INTESTINAL  OBSTRUCTION  AND 
ANASTOMOSIS.  See  Obstruction,  In- 
testinal. 

INTESTINAL  PARASITES.  See 

Parasites. 

INTESTINES. 

Duodenum,  Inflammation  of. 
Synonyms.  — ■  Duodenitis;  duodenal 
catarrh. 

Symptoms. — While  the  possibility  of 
isolated  inflammation  of  the  duodenum 
cannot  be  denied,  it  is  probable  that  the 
condition  is  usually  associated  with  in- 
flammation of  the  stomach,  on  the  one 
hand,  and  of  the  remainder  of  the  small 
intestine,  on  the  other  hand.  Among  the 
symptoms  are  pain,  distress  or  discom- 
fort in  the  right  upper  quadrant  of  the 
abdomen,  impaired  appetite,  bad  taste, 
coated  tongue,  discomfort  from  two  to 
four  hours  after  taking  food,  with  eruc- 
tations and  flatulent  distension.  There 
is  likely  to  be  nausea  and  at  times  there 
is  vomiting,  with  bilious  fluid  in  the 
ejecta.  As  a  rule,  the  bowels  are  con- 
stipated, though  there  may  be  diarrhoea. 
Often,  also,  there  is  jaundice,  from  ex- 
tension of  the  catarrhal  process  to  the 
choledoch-duct  and  resulting  obstruc- 
tion to  the  flow  of  bile,  with  clay-colored 
stools,  etc.  There  may  be,  further,  weak- 
ening and  despondency,  and  possibly 
slight  elevation  of  temperature.  Acute 
or  subacute  attacks  may  last  two  or  three 
weeks,  chronic  attacks  for  as  many 
months. 

The  condition  is  not  a  serious  one,  and 


I  recovery  is  usually  prompt  upon  institu- 
tion of  the  proper  therapeutic  measures. 

Etiology. — The  causative  influences 
include,  in  a  general  way,  irritants  gen- 

I  erated  within  the  body,  as  from  fermen- 
tation or  autointoxication;  or  introduced 

|  from  without,  as  milk,  food,  or  by  acci- 
dent, or  possibly  by  design. 

Treatment. — The  treatment  consists 
primarily  in  a  regulation  of  the  diet,  with 
rigid  restriction  as  to  both  quantity  and 
quality  of  food,  and  perhaps  temporary 
abstinence,  and  recumbency  in  bed,  when 

|  the  symptoms  are  acute.  From  6  to  8 
ounces  of  milk,  peptonized  or  pancre- 
atized  if  not  well  digested  without  prep- 
aration, may  be  given  every  three  hours. 
Unirritating  broths  and  soups,  strained 
gruels,  farinaceous  foods,  boiled  rice  and 

|  soft-boiled  eggs,  albumin-water,  and 
barley-water  may  also  be  permitted. 
Solid  food,  and  especially  the  coarser 
vegetables  and  fruits,  which  leave  con- 

I  siderable  residue,  are  particularly  to  be 

j  avoided.  Small  doses  of  calomel,  1/6 
grain,  may  be  given  at  hourly  intervals 
for  a  short  time,  followed  by  a  saline, 

I  such  as  the  compound  effervescing  (Sed- 

j  litz)  powder,  sodium  phosphate,  sodio- 
potassium  tartrate;  or  the  saline  may 
have  been  given  alone  at  the  outset. 
Counter-irritation,  as  with  a  mustard- 
plaster,  in  the  right  hypochondrium,  may 
relieve  pain  and  allay  nausea  and  vomit- 
ing. If  diarrhoea  be  present  the  salts  of 
bismuth  will  be  indicated,  of  the  sub- 
carbonate  and  subnitrate,  from  10  to  20 
grains;   or  the  salicylate  or  subgallate 

!  from  5  to  10  grains. 

Duodenum,  Ulceration  of. 
Symptoms. — The  clinical  manifesta- 
tions of  ulcer  of  the  duodenum  are  vari- 
able and  but  little  characteristic.  The 
condition  may,  in  fact,  give  rise  to  no 
symptoms  and  be  discovered  only  upon 
I  post-mortem  examination  or  through  the 


140 


INTESTINES.  DUODENUM, 


ULCERATION.  SYMPTOMS. 


occurrence  of  haemorrhage,  perforation, 
suppuration,  peritonitis,  stenosis  of  the 
bowel,  dilatation  of  the  stomach,  or  jaun- 
dice. 

Case  of  a  man,  apparently  in  good 
health,  who  was  seized  during  the  night 
with  sudden,  extreme  diffuse  pain  in  the 
abdomen.    He  died  next  day.    At  the 
autopsy  a  large  oval  ulcer  was  found  in 
the  anterior  wall  of  the  pyloric  orifice. 
Such  cases  are  probably  not  rarely  mis- 
taken for  strangulation  of  the  bowel, 
but  the  rapidity  with  which  collapse  sets 
in  should  nearly  always  serve  to  dis- 
tinguish   them    from    strangulation,  in 
which  collapse  develops  more  gradually. 
Wilberforce    Aikins    (Canadian  Pract., 
Dec.  16,  '91). 
Such  symptoms  as  are  present  re- 
semble closely  those  of  ulcer  of  the 
stomach.   The  most  pronounced  and  the 
most  distinctive  of  these  is  pain  in  the 
right  hypochondrium,  which  is  usually 
less  acute  than  that  of  gastric  ulceration, 
and  is  likely  to  appear  later  after  the 
taking  of  food,  viz.:  two  or  three  hours 
or  more. 

The  symptoms  of  duodenal  ulcer  differ 
but  little  from  those  which  are  met  with 
when  the  disease  occurs  in  the  stomach. 
Pain  is  much  oftener  absent  in  the  duo- 
denal disease. 

When  present,  it  is  often  extremely 
severe,  making  the  patient  writhe  while 
it  lasts;  it  may  occur  at  regular  in- 
tervals, without  reference  to  food ;  or, 
if  due  to  food,  it  is  said  to  begin  from 
two  to  four  hours  after  the  meal,  but 
may,  doubtless,  occur  as  early  as  half 
an  hour.  The  occurrence  of  such  pain 
in  the  right  hypochondrium.  in  absence 
of  other  symptoms,  is  considered  suffi- 
cient by  some  to  establish  a  diagnosis 
of  duodenal  ulcer. 

As  to  the  significance  of  haemorrhage, 
in  the  absence  of  causes,  in  the  lower 
bowel,  sudden  profuse  discharge  indicates 
strongly  the  duodenum  as  the  seat  of 
bleeding,  as  do  also  repeated  small  bleed- 
ings; in  the  latter  case  the  blood  is  all 
tarry.  In  gastric  haemorrhage,  if  small, 
the  blood  passed  by  the  bowel  will  prob- 
ably be  found  more  altered  by  the  action 


of  the  gastric  fluid,  and,  if  large,  the 
vomiting  will  be  more  prominent  than 
the  alvine  evacuations;  while  the  con- 
verse probably  holds  true  when  the 
bleeding  is  duodenal.  Wilson  Fox 
("Reynolds's  System  of  Med.,"  '91). 

The  pain  is  at  times  spontaneous,  and 
it  can  usually  be  induced  or  intensified 
by  pressure.  At  times  it  recurs  in  severe 
paroxysms,  radiating  to  the  epigastrium 
and  the  sacrum.  At  other  times  there  is 
only  a  sense  of  vague  discomfort  or  of 
pressure  or  of  tension.  Occasionally 
there  is  a  feeling  of  hunger,  of  gnawing, 
of  corrosion,  or  of  the  presence  of  a 
foreign  body.  Earely  a  tumor  can  be 
felt.  The  appetite  may  be  unaffected 
and  the  bowels  regular.  Dyspeptic 
symptoms,  if  present  at  all,  are  not  pro- 
nounced. Exceptionally  there  is  diar- 
rhoea, but  more  commonly  there  is  con- 
stipation. Vomiting  is  not  usual,  but 
when  it  does  occur,  it  takes  place  usually 
after  a  paroxysm  of  pain  or  in  conse- 
quence of  a  complicating  gastric  disorder 
or  perhaps  of  cicatricial  stricture  of  the 
duodenum  close  to  the  pylorus.  Unless 
the  vomitus  contain  blood  it  is  not  dis- 
tinctive. Haemorrhage  is  one  of  the 
more  common  symptoms,  and  it  may  be 
slight  or  copious.  The  blood  may  be 
vomited,  or  it  may  be  passed  by  the 
bowel,  or  it  may  be  expelled  in  both 
these  ways.  The  loss  of  blood  may  be 
sufficient  to  cause  death  without  the  es- 
cape of  blood  externally.  Jaundice  oc- 
curs rarely  and  may  then  be  attributed 
to  cicatricial  constriction  of  the  chole- 
doeh-duct.  The  disorder  may  be  of  long 
duration  and  recurrence  is  not  rare  after 
recovery  has  taken  place.  Death  may  re- 
sult   suddenly    from    perforation  or 

haemorrhage. 

Certain  signs  indicate  the  occurrence 
of  intestinal  perforation  before  perito- 
nitis manifests  itself.  The  cardiac  and 
respiratory1  murmurs  can  be  heard  dis- 
tinctly on  auscultation  of  the  abdomen. 


INTESTINES.    DUODENUM,  ULCERATION.    ETIOLOGY  AND  PATHOLOGY.  141 


the  phenomenon  being  due  to  the  pres- 
ence of  intestinal  gas  in  the  peritoneal 
cavity;  a  more  important  sign,  however, 
is  the  modification  in  the  pulse,  the  be- 
ginning of  intestinal  perforation  being 
marked  by  an  acceleration,  which  is  fol- 
lowed within  a  few  hours  by  slackening. 
The  latter,  due  to  the  absorption  of 
putrid  gas's  acting  as  a  cardiac  poison,  is, 
apart  from  its  diagnostic  significance,  of 
considerable  importance  from  a  surgical 
point  of  view,  indicating  the  most  op- 
portune moment  for  operation.  L.  A. 
Gluzinski  (La  Semaine  Med.,  Nov.  6, 
'95). 

Diagnosis. — The  diagnosis  may  be  at- 
tended with  much  difficulty;  in  fact,  the 
condition  may  escape  detection.  The 
pain  and  tenderness  of  duodenal  ulcera- 
tion are  situated  rather  more  to  the  right 
than  that  of  gastric  ulceration,  while  the 
pain  induced  by  the  taking  of  food  oc- 
curs, as  a  rule,  later  with  the  former  than 
with  the  latter;  and  when  haemorrhage 
occurs  the  blood  is  more  likely  to  be 
passed  by  the  bowel  than  to  be  vomited. 
From  malignant  disease  ulceration  of  the 
duodenum  is  to  be  differentiated  usually 
by  the  absence  of  a  tumor  and  of  cachexia 
and  by  the  greater  likelihood  of  haemor- 
rhage, by  the  acidity  of  the  gastric  juice, 
with  the  presence  of  free  hydrochloric 
acid.  The  paroxysms  of  pain  may  simu- 
late biliary  colic,  but  with  the  latter 
jaundice  is  more  common,  the  symptoms 
of  digestive  derangement  are  less  pro- 
nounced, the  symptoms  in  general,  or 
their  aggravation,  are  less  related  to  the 
taking  of  food,  and  there  is  an  absence  of 
emesis  and  of  haemorrhage  from  the 
bowel. 

There  is  great  probability  of  duodenal 
ulcer  when  a  patient,  apparently  in  good 
health,  has  melsena  or  haematemesis,  with 
pain  just  under  the  liver,  to  the  right  of 
the  median  line,  a  few  hours  after  eating, 
with  no  gastric  disturbance  and  a  prompt 
return  of  appetite  after  the  haemorrhage. 
Collins  (Revue  Inter,  de  Bibliog.,  June 
10,  '94). 


Etiology  and  Pathology. — Ulceration 
of  the  duodenum  is  analogous  to  the 
same  lesion  as  it  occurs  in  the  stomach, 
and  it  has  much  the  same  etiology,  path- 
ology, morbid  anatomy,  and  treatment. 
The  process  is,  however,  much  less  com- 
mon in  the  duodenum  than  in  the  stom- 
ach, in  a  proportion,  as  given  by  various 
authorities,  varying  from  1-9  to  1-40. 
Sometimes  ulceration  is  present  in  both 
stomach  and  duodenum  in  the  same  case. 
The  condition  is  due,  in  the  majority  of 
cases,  to  the  action  of  the  gastric  juice 
upon  portions  of  the  mucous  membrane 
whose  vitality  is  lowered  by  any  one  of  a 
number  of  conditions,  viz.:  venous  stasis, 
haemorrhage,  ischuria  (thrombosis,  em- 
bolism, vascular  spasm,  arteriosclerosis), 
hyaline  degeneration  of  the  walls  of  the 
arteries,  traumatism,  etc.  The  affection 
is  observed  most  commonly  between  the 
ages  of  20  and  60,  the  prevalence  being 
fairly  equal  in  several  decades.  Occa- 
sionally it  is  encountered  in  infants. 
Males  surfer  in  larger  number  than 
females,  the  proportion  being  given  as 
3  to  1. 

In  investigating  the  records  of  17,652 
post-mortem  examinations  at  Guy's  Hos- 
pital the  authors  found  70  cases  in  which 
there  was  an  ulcer  of  the  duodenum, 
either  open  or  healed.  It  is  much  rarer 
than  gastric  ulcer. 

The  authors'  cases  give  a  proportion 
of  52  males  to  17  females,  or,  if  burns 
be  excluded,  48  males  to  16  females, — a 
ratio  of  3  to  1.  The  total  of  the  col- 
lected cases  gives  109  males  to  48  females, 
or,  excluding  burns,  of  100  males  to  30 
females.  Thus,  while  duodenal  ulcer  is 
three  times  as  common  in  males  as  in 
females,  gastric  ulcer  is  twice  as  common 
in  females  as  in  males.  Perry  and  Shaw 
(Guy's  Hosp.  Reports,  vol.  1,  p.  171). 

The  lesion  is  commonly  situated  close 
to  the  pylorus.    Usually  there  is  but  a 
single  ulcer;  occasionally  there  are  more. 
I  The  ulcer  varies  in  size  and  depth. 


142      INTESTINES.    DUODENUM,  ULCERATION.    PROGNOSIS.  TREATMENT. 


The  simple  ulcer  of  the  duodenum  is 
usually  round.  Sometimes,  however,  it 
is  oval,  angular,  or  even  irregular.  In 
size  it  is  most  variable.  Generally,  the 
ulcer  is  more  or  less  perpendicular  to 
the  walls  of  the  intestine.  When  the 
ulcer  is  very  chronic,  the  cicatricial  con- 
traction occasions  considerable  deform- 
ity of  the  adjacent  parts.  Extension  to 
the  neighboring  arteries  appears  to  occur 
in  the  following  order  of  frequency:  the 
pancreatico-duodenal,  the  right  gastro- 
epiploic, the  hepatic,  and  then  the  pan- 
creatic artery.  Perforation  is  the  com- 
plication most  to  be  dreaded.  In  262 
cases  perforation  occurred  181  times. 
Collin  (These  de  Paris,  '94). 

In  the  process  of  cicatrization  it  may 
cause  stenosis  of  the  bowel,  or,  if  situated 
close  to  the  papillae  of  Vater,  it  may  in 
the  same  way  cause  obstruction  of  the 
choledoch  and  pancreatic  ducts.  The 
portal  vein  may  suffer  obstruction  from  a 
like  cause,  with  the  development  of 
thrombosis  and  the  attendant  train  of 
symptoms.  The  ulcer  may  perforate 
into  the  peritoneal  cavity  and  thus  cause 
death  from  shock  or  diffuse  peritonitis; 
or  by  erosion  of  a  blood-vessel  it  may  give 
rise  to  copious  haemorrhage.  Perfora- 
tion may  also  take  place  into  an  adjacent 
viscus,  or  through  the  abdominal  wall, 
giving  rise  to  the  development  of  sub- 
cutaneous emphysema  or  the  formation 
of  a  duodenal  fistula.  Often  there  is  cir- 
cumscribed peritonitis  about  the  site  of 
the  ulcer,  with  adhesions  to  contiguous 
organs.  Carcinoma  develops  at  times  in 
the  seat  of  previous  ulceration  of  the 
duodenum. 

Prognosis. — The  prognosis,  while  per- 
haps a  little  uncertain,  is,  on  the  whole, 
favorable,  providing  the  disease  is  recog- 
nized and  intelligently  treated.  There 
is,  of  course,  the  danger  of  fatal  haemor- 
rhage as  well  as  of  perforation  and  peri- 
tonitis, while  recurrence  is  not  rare,  and 
carcinoma  may  develop  at  the  site  of  pre- 
vious ulceration.    The  aUVction  is  some- 


times exceedingly  unyielding  to  treat- 
ment, and  its  duration  may  be  pro- 
tracted. 

Treatment. — The  treatment  does  not 
differ  essentially  from  that  laid  down  for 
gastric  ulcer,  and  includes  rest  in  bed;  a 
bland,  unirritating,  nutritious  diet,  in- 
cluding especially  predigested  milk;  and 
the  administration  of  alkalies,  prepara- 
tions of  bismuth,  and  iron.  Haemor- 
rhage will  demand  absolute  rest,  absti- 
nence from  food  by  the  mouth,  and  the 
administration  of  opium  and  perhaps 
also  of  ergot.  The  local  aplication  of  an 
ice-bag  may  prove  serviceable.  A  single 
copious  haemorrhage  or  repeated  free 
bleeding  may  justify  surgical  interven- 
tion and  cauterization  or  ligature  of  the 
bleeding  point.  There  is  justification, 
further,  for  excision  of  the  ulcer  to  re- 
move the  possibility  of  the  subsequent 
development  of  carcinoma. 

Case  of  perforated  duodenal  ulcer 
cured  by  operation.  A.  Landerer  and 
Gluecksmann  (Mit.  aus  den  Grenzge- 
bieten  der  Med.  Chir.,  B.  1,  H.  2). 

Burns  of  the  surface  are  sometimes  at- 
tended with  ulceration  of  the  gastro- 
intestinal tract,  most  commonly  in  the 
duodenum,  but  occasionally  in  other  por- 
tions.   (See  Burns,  volume  ii.) 

Ulceration  of  the  duodenum  after 
burns  is  due  to  septic  infarction  of  the 
vessels  of  the  duodenum,  the  gastric 
juice  then  acting  upon  the  parts  cut  off 
from  the  vascular  supply.  Marmaduke 
Sheild  (Brit.  Med.  Jour./ Oct.  27,  '94). 

The  usual  seat  in  the  duodenum  is  the 
superior  horizontal  portion  not  far  from 
the  p37lorus.  There  may  be  a  single  ulcer 
or  several.  The  lesion  may  assume  all 
grades  of  severit}',  from  a  simple  erosion 
to  deep  loss  of  substance.  There  may  be, 
besides,  diffuse  inflammation  of  the  mu- 
cous membrane.  The  process  is  a  rapid 
one  and  it  may  quickly  cause  death;  al- 


INTESTINES.    TYPHLITIS.  DIAGNOSIS. 


143 


though,  on  the  other  hand,  the  symptoms 
may  be  deferred  for  some  time. 

Ulceration  of  the  duodenum  may 
occur  also  from  other  causes,  such  as  em- 
bolism, thrombosis,  as  in  the  course  of 
endocarditis,  atheroma,  pulmonary  ab- 
scess, amyloid  disease,  catarrhal  or  fol-  ! 
licular  disease,  or  tuberculosis. 

Caecum,  Diseases  of. 

Synonyms.  —  Typhlitis;    caecitis;  in- 
flammation of  the  caecum;  paratyphlitis;  j 
perityphlitis. 

Symptoms.  —  The    most    distinctive  j 
symptom  of  typhlitis  is  pain  or  a  sense  ! 
of  discomfort  in  the  right  iliac  region. 
With  this  there  is,  as  a  rule,  associated 
constipation,  although  there  may  be 
diarrhoea.    The  appetite  is  likely  to  be 
impaired,  the  tongue  to  be  coated,  the 
breath  to  be  offensive,  a  bad  taste  to  be 
present,  and  there  may  be  tympanites,  as 
well  as  nausea  and  vomiting.    The  tem- 
perature is  but  little  affected  and  the 
constitutional  disturbance  is  inconsider- 
able.   The  presence  of  faecal  masses  in  j 
the  bowel  may  give  rise  to  a  palpable  ! 
tumor,  yielding  dullness  on  percussion.  ! 
Extension  of  the  disease-process  to  the 
appendix  will  induce  additional  symp- 
toms elsewhere  described  as  characteris- 
tic of  this  condition.    Inflammation  of 
the  connective  tissue  or  of  the  peri- 
toneum surrounding  the  caecum  will  be  i 
attended,  in  addition  to  febrile  manifes-  I 
tations  and  a  general  aggravation  of 
existing   symptoms,   with   a   sense   of  ! 
doughy  induration  on  palpation,  on  the 
one  hand,  perhaps  progressing  to  suppu- 
ration, with  the  possibility  of  rupture 
into  the  peritoneal  cavity;  and,  on  the 
other,  with  the  development  of  signs  of 
peritonitis,  which  may  remain  localized 
or  become  diffuse. 

Diagnosis.— The  diagnosis  of  typh- 
litis is  to  be  made  from  the  mildness  of 
the  symptoms,  and  the  readiness  with 


which  they  yield  to  appropriate  treat- 
ment, and  the  absence  of  evidences  of 
constitutional  disturbance.  As  has  al- 
ready been  intimated,  the  differentiation 
from  appendicitis  is  exceedingly  difficult 
and  oftentimes  impossible,  by  reason  of 
anatomical  peculiarities.  Appendicitis, 
comparatively,  may  be  looked  upon  as 
the  graver  of  the  two  conditions,  and  its 
symptoms  may  be  considered  the  more 
marked  and  the  less  yielding  to  treat- 
ment. Under  favorable  conditions  it 
may  be  possible  to  distinguish  by  palpa- 
tion between  an  inflamed  caecum  and  an 
inflamed  appendix.  It  is  doubtful  if 
paratyphlitis  and  perityphlitis  are  to  be 
differentiated  from  para-appendicitis 
and  periappendicitis.  (See  Appendi- 
citis, volume  i ) 

Etiology. — Isolated  inflammation  of 
the  caecum  is  probably  an  uncommon 
condition,  if  it  occur  at  all.  On  the 
other  hand,  typhlitis  will  be  found,  as  a 
rule,  to  accompany  enteritis  and  colitis, 
and  also  appendicitis,  with  the  symptoms 
of  each  of  which  its  own  symptoms  are 
likely  to  be  blended. 

Cause  of  all  typhlitis  and  perityphlitis 
and  paratyphlitis  assigned  to  an  inflam- 
matory process  in  the  appendix,  due  to 
its  occlusion  either  by  faeces,  fgecal  cal- 
culi, stricture,  or,  more  seldom,  foreign 
bodies.  Schede  (Deut.  med.  Woch.,  June 
8,  '92). 

Perityphlitis  is  unusually  common  in 
America,  due  to  two  of  our  natural  fail- 
ings: eating  too  much  and  chewing  too 
little,  the  result  of  which  is  constipation. 
Lange  (N.  Y.  Med.  Jour.,  June  6,  '91). 

The  caecum  may,  with  the  adjacent 
bowel,  be  the  seat  also  of  tuberculous, 
syphilitic,  typhoid,  or  dysenteric  infil- 
tration, and  perhaps  secondary  ulcera- 
tion. The  symptomatology  attributed  in 
the  past  to  syphilis  was  largely  con- 
structed from  the  manifestations  of 
what  we  have  learned  to  recognize  as 
appendicitis.   At  the  same  time,  the  pos- 


144 


INTESTINES.    TYPHLITIS.  TREATMENT. 


sibility  of  catarrhal  inflammation  of  the 
caecum  cannot  be  denied.  Such  a  condi- 
tion may  arise  in  consequence  of  the 
presence  of  irritants,  either  introduced 
from  without  or  generated  within  the 
body;  but,  as  has  been  stated,  the  re- 
sponsible agencies  do  not  confine  their 
activities  to  the  head  of  the  colon.  The 
long-continued  presence  of  hardened 
faecal  masses  in  the  caecum  may  cause 
irritation  and  give  rise  to  ulceration, 
with  the  development  of  either  paratyph- 
litis, inflammation  of  the  connective  tis- 
sue surrounding  the  caecum;  or  peri- 
typhlitis, inflammation  of  its  peritoneal 
covering;  and  these  may  be  responsible 
in  time  for  more  remote  complications. 
This  train  of  events,  it  may  be  concluded 
from  the  experience  of  recent  years,  is 
like  typhlitis  itself,  rather  uncommon, 
so-called  paratyphlitis  being  in  the  vast 
preponderance  of  cases  para-appendicitis 
and  periappendicitis. 

Prognosis. — The  prognosis  of  simple 
catarrhal  typhlitis  is  favorable.  Recov- 
ery is  the  rule  under  judicious  treatment, 
though  recurrence  may  take  place  on  re- 
newal of  the  provocative  conditions. 
The  prognosis  is  rendered  grave  by  the 
development  of  paratyphlitis  and  graver 
by  that  of  perityphlitis,  both  of  which 
may  lead  to  fatal  suppurative  peritonitis. 

Treatment. — The  treatment  of  typh- 
litis is  essentially  an  eliminative  and 
antiphlogistic  one,  and  will  be  partly 
medicinal  and  partly  dietic.  It  is  best, 
even  in  mild  cases,  for  the  patient  to  go 
to  bed,  and  be  placed  under  conditions  of 
rest  and  quiet.  The  diet  should  be  bland 
and  unirritating,  and  so  constituted  as  to 
give  rise  to  the  least  residuum  possible. 
A  suitable  dietary  can  be  constructed 
with  milk  as  a  basis,  and  including  soft- 
boiled  eggs.  Vegetables  and  solid  food 
in  general  had  better  be  avoided.  If  the 
stomach  be  irritable,  food  may  be  with- 


held entirely  for  twenty-four  or  even 
forty-eight  hours.  As  constipation  is  the 
rule,  the  bowels  are  to  be  moved,  and 
preferably  by  means  of  enemata  given 
with  the  aid  of  a  fountain-syringe.  For 
this  purpose,  a  quart  or  two  quarts  of 
simple  warm  water  may  be  used;  or  soap- 
suds may  be  added;  or  1  or  2  ounces  of 
castor-oil,  or  olive-oil,  or  cotton-seed  oil, 
or  oil  of  turpentine,  perhaps  emulsified 
with  the  yelk  of  an  egg.  If  the  constipa- 
tion prove  obstinate,  irrigation  of  the 
bowel  with  larger  quantities  of  water 
may  be  practiced. 

The  best  treatment  of  perityphlitis  is 
removal  of  the  intestinal  contents  in 
every  possible  way,  especially  by  wash- 
ing out  the  stomach.  If  the  stomach  is 
washed  out  soon  after  the  onset  of  faecal 
stoppage,  the  faecal  masses  removed,  and 
this  done  two  or  three  times  daily,  the 
intestines  may  be  relieved,  and  the  de- 
composition of  their  contents  and  ab- 
sorption of  toxic  substances  prevented. 
Good  effects  from  this  treatment  re- 
peatedly observed.  Ewald  (Berl.  klin. 
Woch.,  No.  18,  '91). 

When  the  constipation  has  been  over- 
come small  doses  of  calomel,  1/6  grain 
hourly  for  six  doses,  followed  by  a  saline 
— magnesium  sulphate,  sodio-potassium 
tartrate,  sodium  phosphate,  from  2  to  4 
drachms,  may  be  given;  or,  if  the  con- 
stipation was  aggravated  originally,  the 
saline  may  have  been  given  at  the  outset, 
preceded  or  not  by  5  grains  of  calomel. 
If  the  bowels  be  loose  and  pain  be  a 
prominent  symptom,  opium  may  be  in- 
dicated, though  deceptive  masking  of  the 
symptoms  by  the  anodyne  is  to  be 
guarded  against. 

The  development  of  paratyphlitis  and 
perityphlitis  will  demand,  in  addition  to 
the  measures  already  specified,  local  ap- 
plications, preferably  of  cold,  or,  if  that 
be  badly  borne,  of  heat:  and  counter- 
irritation   and    sorbefacient  ointments 


INTESTINES.    COLON,  DILATATION.  SYMPTOMS. 


145 


when  the  process  manifests  a  tendency 

to  become  chronic. 

Medical  treatment  of  perityphlitis  de- 
fended against  surgical  interference.  The 
plan  of  treatment  is  rest,  free  evacuation 
of  the  bowels,  hot  fomentations  or  ice- 
bags,  with  the  addition,  in  chronic  cases, 
of  repeated  blistering  over  the  tumor. 
Saundby  (Birmingham  Med.  Review, 
Sept.,  '91). 

Results  in  65  cases  of  perityphlitis. 
Thirty-four  cases  were  cured,  25  im- 
proved, 2  uncured,  3  died,  and  1  trans- 
ferred. In  the  commencement  the  treat- 
ment is  antiphlogistic:  leeches  (up  to 
ten)  are  first  applied,  and  then  ice  or 
Leiter's  coil.  When  cold  does  not  agree, 
then  warmth  in  the  form  of  a  mush 
poultice  is  applied.  Later  the  parts  are 
painted  with  iodoform  collodion,  to 
which  equal  parts  of  the  tincture  of 
iodine  and  tincture  of  nut-galls  have 
been  added.  To  hasten  absorption,  sapo 
viridis  is  rubbed  in.  The  diet  is  to  be 
attended  to  and  compound  tincture  of 
cinchona  given;  also,  opium, — not  in  all 
cases,  however.  As  the  affection  sub- 
sides, if  the  bowels  do  not  move  spon- 
taneously, enemas  may  be  given,  or  com- 
pound licorice  powder  or  Carlsbad  salts. 
For  chronic  cases  with  persistent  ex- 
udate, warm,  moist  applications  with 
massage  are  advised.  Purgatives  should 
also  be  employed.  Operation  is  to  be 
advised  when  pus  is  demonstrated  to  be 
present.  J.  Vollert  (Deut.  med.  Woch., 
Aug.  13,  20,  '91). 

In  cases  of  indolence  of  the  caecum 
external  treatment,  friction  and  massage 
of  the  abdomen,  with  the  continuous 
current,  if  necessary,  are  employed,  and 
if  there  is  any  congestion  of  the  caecum 
or  pericecal  ganglia  the  parts  are  painted 
with  tincture  of  iodine  or  small  blisters 
applied.  The  diet  is  of  great  importance, 
and  no  solid  foods  should  be  taken,  but 
meats,  fish,  etc.,  be  reduced  to  a  fine 
pulp,  and  vegetables  be  given  in  the 
form  of  a  puree.  Jules  Simon  (Revue 
Gen.  de  Clin,  et  de  Ther.  Jour,  des  Prat., 
Jan.  19,  '95). 

Suppuration  will  and  peritonitis  may 
demand  surgical  intervention.  (See  Ap- 
pendicitis, volume  i.) 

4—10 


When  there  is  severe  localized  pain, 
tenderness,  and  a  tumor  present  in  the 
right  iliac  region,  with  the  constitu- 
tional symptoms  of  suppurative  inflam- 
mation, an  early  operation  is  demanded 
to  evacuate  the  pus.  This  should  be 
done  as  early  as  the  third  day  when 
possible.  Delay  is  more  dangerous  than 
operation.  R.  Winslow  (Va.  Med. 
Monthly,  May,  '91). 

One  ought  not  to  seize  on  and  explore 
every  perityphlitic  abscess,  more  par- 
ticularly when  the  proof  of  its  existence 
is  doubtful  and  only  a  mere  suspicion. 
When  general  peritonitis  sets  in  as  a 
complication,  surgical  treatment  is  neces- 
sary. Ewald  (Berl.  klin.  Woch.,  No.  18, 
'91). 

Resection  of  the  caecum  recommended 
when  it  is  perforated.  Von  Winiwarter 
(Annales  de  la  Soc.  Medico-chir.,  June, 
'92). 

Colon,  Dilatation  of. 
Symptoms. — Apart  from  the  symp- 
toms of  any  primary  condition  that  may 
be  operative,  dilatation  of  the  colon  is 
characterized  especially  by  distension  of 
the  abdomen  of  varying  degree,  yielding 
a  tympanitic  note  on  percussion.  Con- 
stipation, further,  is  a  prominent  feature, 
and  may  be  marked.  Sometimes  there 
occur  in  association  numerous  small, 
liquid  stools,  together  with  ungratified 
desire  for  or  ineffectual  effort  at  defeca- 
tion. There  is  also  general  discomfort 
in  proportion  to  the  degree  of  distension 
and  the  resulting  displacement  and  in- 
terference with  function  of  adjacent  or- 
gans. Bladder,  uterus  and  appendages 
may  be  crowded  into  the  pelvis;  lungs, 
liver  and  heart  pushed  high  up  into  the 
thoracic  cavity.  Digestion  is  naturally 
deranged,  nutrition  suffers,  weight  is 
lost,  and  the  quality  of  the  blood  de- 
teriorates. 

The  symptoms  of  atony  of  the  intes- 
tines are  marked  constipation,  headache, 
vertigo,  nausea,  and  pains  in  the  bade 
and  loins.  Nervous  symptoms  are  often 
present.    The  signs  are  marked  tympany 


146 


INTESTINES.    COLON,  DILATATION.  ETIOLOGY. 


and  sometimes  the  ability  to  detect  the 
distended  colon  and  faecal  masses  by  pal- 
pation. By  giving  an  enema  of  6  1/2  to 
9  Va  fluidounces  of  water,  splashing  can 
be  heard,  while  normally  1  pint  will  be 
required  to  produce  the  sound.  Frieden- 
wald  (Med.  News,  Aug.  11,  '94). 

Introduction  of  a  large  quantity  of 
water  into  the  intestine  in  order  to  diag- 
nose a  condition  of  atony  or  dilatation 
recommended.  From  1  to  pints  are 
necessary  in  order  to  produce  the  splash- 
ing sound  in  the  normal  intestine,  per- 
ceptible in  the  neighborhood  of  the  trans- 
verse and  descending  colon;  while  only 
3/b  or  V5  pint  will  produce  the  sound  if 
there  is  atony  or  dilatation;  and  in 
such  a  case  it  is  perceptible  first  in  the 
sigmoid  flexure,  then  in  the  transverse 
colon,  and  finally  in  the  entire  large  in- 
testine. Change  of  position  produces  a 
succussion-sound,  and  dilatation  of  the 
sigmoid  flexure  may  be  ascertained, 
which  may  be  beyond  the  median  line. 
In  the  same  manner  displacement  of  the 
transverse  colon  may  be  determined,  and 
if  simple  atony  only  is  present  the  splash- 
ing will  be  heard  in  the  normal  position 
of  the  colon,  while  if  there  is  also  dis- 
placement the  sound  will  be  heard  under 
the  umbilicus.  It  is  indispensable  to 
evacuate  the  intestine  with  a  purgative 
before  performing  this  lavage.  In  catarrh 
of  the  intestine  the  water  will  return 
charged  with  mucus  and  false  membrane, 
while  if  the  intestine  is  normal  the  water 
will  be  clear  or  will  contain  only  some 
slight  epithelial  debris.  Boas  (Deut. 
med.  Zeit.,  Jan.  15,  '95). 

Etiology. — Dilatation  of  the  colon 
may  arise  from  a  variety  of  causes,  the 
essential  element  being  invariably  an 
atonic  state  of  the  muscular  coat  of  the 
bowel. 

This  may  result  from  long-protracted 
catarrhal  conditions,  from  fgecal  accumu- 
lation, and  from  other  forms  of  chronic 
intestinal  obstruction,  such  as  the  pres- 
ence of  neoplasm,  or  of  a  foreign  body, 
or  of  constriction  from  without  or 
within,  and  the  like. 

Atony  of  the  intestine  separated  from 
chronic  constipation,  which  is  often  only 


a  symptom  of  the  former  condition.  The 
atony  usually  affects  the  colon,  which 
is  unable  to  expel  the  faeces.  It  may  be 
primary,  as  the  result  of  improper  diet, 
sedentary  habits,  or  a  too  frequent  use 
of  cathartics;  or  it  may  be  secondary 
to  many  disorders,  as  obesity,  disease  of 
the  heart,  lungs,  or  liver,  typhoid  fever 
and  other  intestinal  diseases,  or  organic 
nervous  diseases.  It  is  often  found  in 
childhood  and  may  be  congenital.  Frie- 
denwald  (Med.  News,  Aug.  11,  '94). 

Literature  of  '96-'97-'98. 

In  cases  of  marked  tympanites  the 
distension  is  practically  confined  to  the 
large  intestine,  and  it  would  appear  that 
the  obstruction  to  the  escape  of  flatus 
is  due  to  the  downward  pressure  of  the 
descending  colon  and  sigmoid  flexure 
upon  the  upper  portion  of  the  rectum, 
forcing  the  folds  of  Houston  one  upon 
the  other,  and  bringing  about,  in  this 
way,  what  is  for  the  time  in  effect  an 
impermeable  stricture. 

The  most  rational  method  of  relieving 
this  obstruction  and  liberating  the  im- 
prisoned gas  is  the  inversion,  or  partial 
inversion,  of  the  patient,  and  removal 
through  the  aid  of  gravitation  of  the 
pressure  from  above,  which  has  con- 
verted the  mucous  folds  referred  to  into 
an  absolute  obstruction. 

While  the  knee-chest  position  may 
answer  best  in  cases  of  extreme  dis- 
tension, the  placing  of  the  patient  upon 
the  side,  with  elevation  of  the  foot  of 
the  bed,  will  commonly  secure  relief  in 
cases  of  moderate  distension.  Lesslie  M. 
Sweetnam  (Annals  of  Surg.,  Mar.,  '96). 

At  times  the  condition  is  present  from 
early  life  and  in  rare  instances  it  has  been 
thought  to  be  congenital. 

Literature  of  'dG-'M-W. 

Case  of  a  child.  3Va  years  of  age, 
male,  who  from  birth  was  extremely 
constipated.  No  action  of  bowels  with- 
out purgatives.  For  the  first  year  there 
was  no  enlargement  of  abdomen,  and  the 
child  was  in  no  pain.  At  the  end  of  the 
first  year  gradual  and  progressive  en- 
largement of  the  abdomen  supervened. 

At  the  age  of  3  1/3  years  constipation 


INTESTINES.    COLON,  DILATATION.  ETIOLOGY. 


147 


became  alarming,  and  no  flatus  was 
passed.  The  distension  and  pain  became 
more  marked  than  ever  before,  while 
purgatives  and  enemata  seemed  useless. 

On  admission  to  the  hospital  the  ab- 
domen was  much  distended  and  uni- 
formly enlarged.  There  were  vermicular 
movements  over  the  lower  part  of  the 
abdomen,  apparently  associated  with  the 
distended  colon.  This  colon  could  be 
felt  as  an  elongated  prominence,  running 
obliquely  across  the  abdomen,  and  vary- 
ing in  position  from  time  to  time.  Move- 
ments were  both  spontaneous  and  ex- 
cited by  examination.  Laparotomy  was 
performed,  no  stricture  found.  A  second 
operation  in  the  left  inguinal  region,  in 
order  to  empty  the  colon,  met  only  with 
partial  success,  it  being  impossible  to 
really  empty  the  intestine.  Five  days 
later  the  patient  showed  signs  of  perfor- 
ative peritonitis  and  died.  At  the  au- 
topsy, there  was  a  little  recent  peri- 
tonitis. "The  lower  half  of  the  abdomen 
is  occupied  by  the  enormously  distended 
and  hypertrophied  sigmoid  flexure,  which 
lies  completely  across  the  abdominal 
cavity  with  the  concave  border  looking 
to  the  left.  The  upper  half  of  the  loop 
is  the  wider  and  longer,  measuring  20 
centimetres  by  8  centimetres,  while  the 
lower  half  is  15  centimetres  long  by  5 
centimetres  in  diameter.  .  .  .  There 
seems  to  be  a  thickening  of  that  part  of 
the  mesocolon  which  approximates  the 
two  ends  of  the  loop  and  causes  traction 
on  the  lower  end,  thus  creating  a  partial 
narrowing  of  the  lower  portion."  The 
wall  of  sigmoid  and  descending  colon  was 
much  thickened;  there  was  no  ulceration. 
Idiopathic  dilatation  of  the  colon  is  a 
rare  condition. 

Cases  fall  into  four  categories:  (1) 
the  rarest,  those  undoubtedly  of  con- 
genital origin,  of  which  the  author's  case 
is  only  the  fifth  on  record;  (2)  those  in 
which  the  symptoms  come  on  a  few 
months  after  birth — these  cases  are 
closely  allied  to  the  preceding;  and  (3) 
those  developing  some  years  after  birth, 
but  distinct  from  (4)  those  only  occur- 
ring in  adult  life.  The  cause  regarded  as 
being  purely  mechanical.  The  whole  of 
the  colon  may  be  dilated,  but  the  sig- 
moid   flexure    is   almost    invariably  af- 


fected, and  from  this  point  the  dilatation 
spreads  backward  to  a  varying  extent 
of  the  colon.  Treatment  has  been  most 
unsatisfactory.  Purgatives  and  enemata 
have  little  effect,  and  lead  to  increased 
suffering,  while  massage  is  dangerous. 
C.  F.  Martin  (Montreal  Med.  Jour.,  Mar., 
'97 ). 


Fig.  1. — Photograph  of  a  boy,  aged  3  7  s 
years,  with  congenital  idiopathic  dilatation  of 
the  colon. 


When  dependent  upon  obstruction,  of 
whatever  character,  it  follows  hyper- 
trophy in  consequence  of  the  constant 
efforts  at  expulsion  of  the  accumulating 
contents.  In  some  instances  no  form  of 
obstruction  lias  been  discovered,  and  it 


148       INTESTINES.    COLON,  DILATATION.    TREATMENT.  ENTEROPTOSIS. 


may  be  that  in  these  the  condition  may 
have  been  dependent  upon  an  hypoplasia 
of  the  muscular  coat  of  the  bowel.  The 
gut  may  attain  enormous  proportions 
and  it  may  undergo  extraordinary  dis- 
placement and  distortion. 

Case  of  gigantic  intestinal  divertic- 
ulum seen  in  a  boy  aged  14.  The  ab- 
domen began  to  swell  soon  after  birth 
and  continued  till  death,  which  followed 
an  operation  for  relief  of  the  condition. 
It  was  found  at  the  autopsy  that  a  large 
diverticulum  connected  with  the  rectum. 
Maas  (Centralb.  f.  Gynak.,  Apr.  22,  '88). 

Case  in  which  sigmoid  flexure  formed 
two  large  sacs  extending  across  the  ab- 
domen. Money  (Brit.  Med.  Jour.,  Feb. 
4,  '88). 

It  also  becomes  the  repository  for  a 
vast  accumulation  of  faecal  matter,  and  it 
may,  through  acute  dilatation  of  the 
bowel,  attend  inflammation  of  the  peri- 
toneum or  this  mechanism  lead  to  a  fatal 
issue  of  some  organ  with  a  peritoneal 
covering. 

Treatment. — The  treatment  consists 
in  the  prevention  of  the  causative  con- 
ditions when  possible,  of  their  removal 
when  present,  and  of  their  effects  when 
these  have  developed,  with  a  proper 
regard,  of  course,  for  the  general  state  of 
the  patient.  Thus,  constipation  is  to  be 
prevented  by  attention  to  and  regulation 
of  the  diet,  and  to  be  judiciously  cor- 
rected when  it  exists,  though  the  abuse 
of  purgatives  is  to  be  carefully  guarded 
against.  Accessible  strictures  should  be 
dilated,  obstructing  neoplasms  and  for- 
eign bodies  removed,  and  constricting 
bands  and  confirming  adhesion  freed. 
The  faecal  accumulations  are  best  re- 
moved by  enemata  of  either  water,  warm 
or  cold,  alone,  or  with  the  addition  of 
soap-suds,  castor-oil,  olive-oil,  cotton- 
seed oil,  or  turpentine. 

Large  quantities  of  olive-oil,  varying 
from  a  pint  to  a  quart,  in  divided 
doses,  have  been  successful  in  fsecal  ac- 


cumulations. E.  W.  Mitchell  (Cincin- 
nati Lancet-Clinic,  Jan.  17,  '91). 

Massage  is  capable  of  effecting  good 
results  in  suitable  cases,  and  electricity 
also  at  times.  The  diet  should  be  prefer- 
ably concentrated,  and  food  requiring  in- 
testinal digestion,  or  giving  rise  to  a 
bulky  and  coarse  residue,  must  be 
avoided.  Of  drugs,  strychnine  is,  per- 
haps, the  best,  conjoined  or  not  with 
belladonna,  in  accordance  with  the  pres- 
ence or  absence  of  irritability  of  the 
bowel. 

Enteroptosis.  —  Descent  of  the  intes- 
tines from  their  position  is  a  frequently 
overlooked  condition  occurring  coinci- 
dently  with  gastroptosis,  nephroptosis, 
and  prolapse  of  other  abdominal  organs. 
It  constitutes  the  disorder  termed  by 
Glenard  "splanchnoptosis."  In  rare  cases 
the  condition  may  be  congenital.  Pre- 
disposing causes  may  be  relaxation  of  the 
abdominal  walls  from  numerous  preg- 
nancies or  from  rapid  emaciation;  trau- 
matism; improper  use  of  cathartics;  and, 
in  addition  to  these  general  causes,  there 
must  be  in  every  case  a  relaxation  of  the 
ligaments  and  the  mesentery.  The  con- 
dition, even  when  extreme,  may  be  with- 
out symptoms,  but  usually  there  exist 
signs  of  disordered  functions,  which  may 
affect  the  general  nutrition.  The  appe- 
tite is  generally  lessened,  and  there  are 
sensations  of  weight  and  fullness,  with 
acid  eructations.  In  some  cases  the 
bowels  move  daily,  but  more  often  con- 
stipation prevails,  sometimes  alternating 
with  diarrhoea.  Excessive  flatulence  is 
usual,  and  not  rarely  there  is  mem- 
branous enteritis.  As  a  result  of  these 
abnormal  conditions  there  are  loss  of 
flesh  and  a  feeling  of  weariness,  and  the 
patient  has  the  appearance  of  one  suffer- 
ing from  a  wasting  disease.  Xervous 
symptoms  are  marked,  with  headache, 
loss  of  sleep,  and  other  sensations,  which 


INTESTINES.    COLITIS  DIARRHOEA. 


149 


might  lead  to  a  diagnosis  of  neurasthe- 
nia or  hysteria.  The  course  of  the  dis- 
ease is  chronic.  (Boas.) 

Colon,  Inflammation  of. 
Synonyms. — Colitis;    catarrh  of  the 
colon. 

Definition. — Inflammation  or  catarrh 
of  the  colon  may  be  part  of  the  same 
process  involving  other  parts  of  the  in- 
testinal tract  as  well,  or  it  may  be  more 
or  less  localized  to  the  large  bowel. 

Symptoms. — These  differ  in  accord- 
ance with  the  nature  and  the  continu- 
ance of  the  causative  agent  and  with  the 
extent  and  intensity  of  the  morbid  proc- 
ess. The  most  distinctive  manifestation 
is  looseness  of  the  bowels.  There  may  be 
many  movements  hourly.  The  stools  are 
usually  small  and  they  commonly  con- 
tain mucus;  at  times  they  are  large  and 
contain  much  fluid.  They  may  be  blood- 
streaked.  Often  there  is  abdominal  pain, 
of  varying  degree,  and  sometimes  colicky 
in  character.  Not  uncommonly  there  is 
some  degree  of  tenesmus.  There  may  be 
frequent  ineffectual  desire  for  stool. 
The  temperature  may  be  elevated,  and  in 
cases  of  acute  onset  there  may  be  nausea 
and  vomiting  and  marked  constitutional 
depression.  Appetite  is  generally  lost, 
though  in  chronic  cases  it  may  be  pre- 
served. In  long-standing  cases  nutrition 
fails  and  emaciation  and  weakness  may 
be  marked. 

It  depends,  like  other  forms  of  mu- 
cous-membrane disturbance,  upon  the 
action  of  irritants,  either  generated 
within  the  body,  such  as  the  products  of 
fermentation  or  other  toxic  substances 
resulting  from  some  inadequacy  of  func- 
tion, or  introduced  from  without,  such 
as  indigestible  or  decomposing  food,  or 
an  excess  of  food. 

Mucous  colitis,  or  mucino-membranous 
enteritis,  is  most  often  produced  by  some 
obstruction  to  the  course  of  the  faecal 


matter  resulting  from  haemorrhoids, 
hernia,  constipation,  tumors,  and  other 
affections  of  the  uterus  and  appendages, 
polypi  of  the  rectum  in  the  case  of  chil- 
dren, and  hypertrophy  of  the  prostate. 
There  may  be  no  symptoms  whatever, 
or  there  may  be  symptoms  resembling 
those  of  gastric  dyspepsia  or  even  dila- 
tation. G.  See  (Le  Bull.  Med.,  Dec.  27, 
'93). 

Mucous  colitis  is  associated  nearly  al- 
ways with  habitual  constipation  in 
young  women  the  subjects  of  some 
gynaecological  affection.  There  are  two 
forms  of  the  disease:  the  one  depending 
solely  upon  the  nervous  system,  the 
other  in  intimate  relation  to  a  uterine 
disease.  Moran  (Jour,  de  Med.,  Jan.  21, 
'94). 

Excessive  intestinal  putrefaction  oc- 
curs in  many  conditions,  especially  epi- 
lepsy, chronic  nephritis,  anaemia,  melan- 
cholia, etc.  The  amount  of  ethereal  sul- 
phates in  the  urine  is  an  indication  of 
the  extent  of  fermentation.  Herter 
(N.  Y.  Med.  Jour.,  Jan.  27,  '94). 

Effect  of  temperature  on  intestinal  fer- 
mentation studied,  using  the  ethers  in 
the  urine  as  an  indication  of  the  extent 
of  the  process.  Individual  predisposition 
was  found  to  exert  a  decided  influence. 
A  draught  of  air  over  the  abdomen  of  a 
sleeper  often  increased  fermentation,  al- 
though some  subjects  were  unaffected. 
Local  chilling  with  ice  always  produced 
an  increase  of  fermentation.  L.  Cantu 
(Centralblatt  f.  Bakter.  und  Parasitenk., 
Aug.  15,  '94). 

Literature  of  '96-'97-'98. 

Excessive  intestinal  fermentation  or 
putrefaction,  either  from  excessive  for- 
mation of  moderately-toxic  bodies,  or 
through  the  temporary  appearance  of 
bodies  of  greater  toxicity,  may  cause 
various  forms  of  toxaemia. 

Many  minor  ailments  are  connected 
either  with  excessive  intestinal  fermen- 
tation or  perhaps  with  modified  intes- 
tinal fermentation,  such  as  diarrhoea 
with  offensive  and  perhaps  fermented 
stools,  and  flatulence  with  abdominal 
pain  and  distension.  Also  anaemia,  mal- 
nutrition, vomiting,  headaches,  the  so- 


150 


INTESTINES.    COLITIS  DIARRHOEA.  TREATMENT. 


called  "biliousness,"  and  many  nervous 
manifestations.  R.  N.  Chittenden  (Die- 
tetic and  Hyg.  Gaz.,  June,  '96). 

There  are  two  forms  of  intestinal  fer- 
mentation produced  by  micro-organisms, 
the  one  of  the  carbohydrates,  the  other 
of  the  proteids  present  in  the  gut,  and 
they  are  mutually  antagonistic  to  one 
another.  The  fermentation  of  carbo- 
hydrates leads  to  the  evolution  of  gases, 
and  to  the  formation  of  organic  acids. 
The  gases  cause  discomfort  and  the  acids 
interfere  with  pancreatic  digestion,  but 
the  products  formed  are  not  very  poison- 
ous nor  irritating.  On  the  other  hand, 
the  fermentation  of  proteid  bodies  caused 
by  bacteria  results  in  the  formation  of 
gases  of  more  varied  character,  though 
in  some  cases  no  gas  may  be  evolved, 
and  in  the  production  of  many  deriva- 
tives of  a  poisonous  and  dangerous 
action.  The  fasces  are  most  offensive. 
In  acute  cases  there  are  febrile  symp- 
toms; in  chronic,  depression,  and  nerv- 
ous affections.  Bartley  (Brooklyn  Med. 
Jour.,  Aug.,  '96). 

It  may  be  acute  or  chronic  and  of  vary- 
ing degrees  of  severity. 

Prognosis. — The  prognosis  varies  with 
the  character  of  the  causative  agent  and 
the  general  condition  of  the  patient. 

Treatment. — The  treatment  is  best 
conducted  with  the  patient  in  bed. 
Under  such  conditions  recovery  may  fol- 
low mere  restriction  of  the  diet.  This 
may  include  milk,  strained  broths  and 
soups,  beef-tea,  beef-juice,  farinacea, 
and  possibly  soft-boiled  eggs.  In  aggra- 
vated cases  it  may  be  well  to  withhold  all 
food  for  a  time  and  give  only  albumin- 
water  or  barley-water. 

When  the  condition  is  attributable  to 
improper  food  or  to  the  presence  of  irri- 
tating  intestinal  contents  an  initial  dose 
of  a  teaspoonfnl  each  of  castor-oil  and 
camphorated  tincture  of  opium  may  be 
given. 

Literature  of  'SB-WSS. 

Enterocolitis  contra-indicates  the  use 
of  drastic  purgatives.     Small  doses  of 


senna  with  hydrastis  or  hamamelis  give 
good  results,  if  there  are  bloody  stools. 
Besides  hygienic  measures  (massage, 
Swedish  gymnastics)  and  regulation  of 
diet,  laxatives  and  enemata  advised. 
One  day  a  large  enema  may  be  given, 
and  the  next  day  3  teaspoonfuls  of 
castor-oil.  The  large  injections  must  be 
given  gently,  the  quantity  may  be  1 
litre,  1  V2  litres,  to  2  litres  at  the  most. 
Solutions  of  borax  or  sodium  chloride 
advised,  but  water  containing  boric  acid 
or  naphthol,  which  are  irritants,  con- 
demned. When  there  are  dysenteric- 
stools  the  use  of  nitrate  of  silver  in  1 
to  3000  or  4000  advised.  The  diet  must 
be  free  from  irritating  or  easily-ferment- 
able foods.  M.  Mathieu  (Le  Progres 
Med.,  June  12,  '97). 

Opium  in  some  form,  or  morphine  or 
codeine,  may  be  required  when  the 
bowel-movements  are  unduly  frequent 
and  attended  with  distress  or  pain.  The 
anodyne  may  be  administered  by  the 
mouth  or  by  the  bowel  in  the  form  of  an 
enema  of  starch-water  with  tincture  of 
opium.  In  many  cases  irrigation  of  the 
bowel,  from  three  to  five  times  a  day 
with  from  1  to  3  quarts  of  fluid,  serves 
a  useful  purpose.  Simple  warm  water 
may  be  used  or  boric  acid  (5  grains  to  1 
ounce)  or  thymol  (1/2  grain  to  1  ounce) 
or  silver  nitrate  (1/2  grain  to  1  ounce)  or 
mercuric  chlorid  (1  to  10,000)  may  be 
added  in  suitable  proportion,  care  being 
taken  that  those  solutions  containing 
substances  capable  of  toxic*  activity  be 
not  retained. 

Large  rectal  injections,  or  injections 
of  sufficient  size  to  wash  out  the  sigmoid 
flexure  and  colon,  are  not  sufficiently 
resorted  to,  particularly  in  those  cases 
of  diarrhoea  in  which  a  catarrhal  element 
is  well  marked.  Good  results  are  at- 
tained if  large  clysters  are  given  by 
means  of  an  hydrostatic  syringe  elevated 
not  more  than  eighteen  inches  or  two 
feet  above  the  rectum.  Salicylic  acid 
and  its  relatives,  nitrate  of  silver,  iodo- 
form when  given  in  oil  emulsion,  and 
some  of  the  vegetable  astringents  may 


INTESTINES.    COLITIS  DIARRHCEA.  TREATMENT. 


151 


be  employed  in  the  water.  The  sub- 
stance which  has  always  given  the  writer 
the  best  results  in  the  catarrhal  cases 
is  the  sulphocarbolate  of  zinc  in  the  pro- 
portion of  10  to  30  grains  to  an  injection 
amounting  to  from  2  to  3  quarts.  In 
some  instances  the  water  should  be  tepid, 
in  others  it  should  be  as  hot  as  the 
bowel  can  stand,  and  in  still  others  it 
should  be  quite  cold,  the  temperature 
of  the  injection  depending  largely  upon 
the  acuteness  of  the  inflammatory  proc- 
ess and  the  sensations  of  the  patient. 
If  the  water  be  cold,  care  should  be 
taken  that  undue  chilling  of  the  body 
does  not  result  in  feeble  persons,  or  if 
hot,  on  the  other  hand,  that  a  mild 
degree  of  heat  fever  is  not  produced. 
The  success  of  this  treatment  depends 
absolutely,  in  many  instances,  upon  the 
gentleness  and  care  with  which  the  in- 
jection is  given,  and  the  water  must  be 
allowed  to  trickle  into  the  bowel  rather 
than  to  enter  it  with  any  force. 

In  those  cases  of  chronic  diarrhoea  in 
which  the  patient  is  markedly  emaciated 
and  unable  to  digest  much  food,  so  that 
the  condition  of  impaired  nutrition  is 
an  important  factor  in  preventing  re- 
covery, this  method  of  treatment  is  to 
be  highly  recommended,  and  it  is  worthy 
of  note  that  a  small  rectal  injection, 
amounting  to  an  ounce  or  two  of  iodo- 
form and  sweet-oil  emulsion,  in  the  pro- 
portion of  5  grains  to  the  ounce,  injected 
into  the  bowel  after  a  large  watery  move- 
ment has  passed  away,  will  relieve  any 
tendency  to  tenesmus,  and,  by  the  ab- 
sorption of  a  small  amount  of  iodine, 
exercise  a  useful  influence  over  the  un- 
derlying catarrhal  process.  H.  A.  Hare 
(Therap.  Gaz.,  Apr.  15,  '95). 

Two  cases  of  ulcerative  colitis  cured 
by  enemata  of  nitrate  of  silver,  nitrate- 
of-silver  capsules  by  mouth,  and  a  low 
diet  of  oatmeal,  milk,  and  whey.  Rogers 
(Med.  Review,  Apr.  21,  '94). 

Literature  of  '96-'97-'98. 

Intestinal  irrigation  exercises  no  in- 
fluence upon  the  course  of  tuberculous 
ulceration  of  the  intestine.  It  is  prob- 
ably of  little  or  no  benefit  in  the  ordinary 
cases  of  dyspeptic  diarrhoea  of  infants, 
where  the  small  intestine  is  wholly  or 


mainly  affected.  It  may  be  expected 
to  exercise  a  beneficial  influence  upon  the 
course  of  the  disease  in  general  cases  of 
enterocolitis,  and  especially  in  those  in 
which  the  colon  is  largely  involved.  It 
requires  to  be  carried  out  with  great 
caution,  and  more  especially  so  in  those 
cases  in  which  there  is  considerable  pros- 
tration. Clemow  (Med.  Press  and  Cir., 
Jan.  15,  '96). 

Laboratory  experiments  on  dogs  car- 
ried out  to  determine  the  effect  of  con- 
tinuous intestinal  irrigation  on  the  pulse- 
tension,  temperature,  body  and  blood, 
renal  secretion,  and  intestinal  absorp- 
tion. The  irrigating  fluid  consisted  of 
normal  salt  solution  (1  drachm  of  salt  to 
a  pint  of  water).  The  following  conclu- 
sions reached:  1.  Pulse-tension:  irrigate 
at  100°,  101°,  102°  F.,  or  even  to  103°-104° 
F.,  if  increase  is  to  be  avoided.  If  mod- 
erate increase  is  not  objectionable,  a 
temperature  of  105°  to  108°  F.  can  be 
employed.  If  it  is  desired  to  rapidly 
increase  it  and  to  stimulate  the  heart, 
one  may  irrigate  with  a  temperature  of 
110°  F.  and  increase  it  steadily  to  120° 
F.  This  is  excellent  in  shock  and  allied 
conditions;  before  or  during  severe 
operation,  to  prevent  shock;  and  from 
the  commencement  of  chloroform  anaes- 
thesia, to  prevent  the  sudden  dilatation 
of  the  blood-vessels.  Cold  is  a  temporary 
stimulant,  and  cold  irrigation  will,  for  a 
time,  markedly  increase  it;  later,  it  is 
a  depressant,  and  it  fails.  Cold  should 
therefore  be  employed  with  caution.  2. 
Shock  from  haemorrhage :  irrigation  with 
normal  saline  solution,  110°  to  120°  F., 
in  this  condition.  With  the  double- 
current  method,  the  patient  receives  a 
continuous  enema  at  the  desired  tem- 
perature, and  the  quantity  of  the  fluid 
can  be  absolutely  regulated  by  the 
operator.  3.  Temperature:  hot  irriga- 
tion, 110°  to  120°  F.,  when  prolonged, 
increases  the  temperature  of  the  body 
and  blood. 

Cold  irrigation  reduces  temperature, 
but  is  depressing  after  twenty  to  twenty- 
five  minutes.  Cold  irrigation  has  been 
employed  with  success  to  aid  in  the  re- 
duction of  temperature  in  the  diarrhoeas 
of  children  and  in  dysentery. 

The  temperature  at  the  start  should 


152 


INTESTINES.    COLITIS  DI. 


ARRHCEA.  TREATMENT. 


not  be  below  60°  or  70°  F.  In  duodenal 
jaundice  cold  irrigation  (2  quarts)  and 
the  alternate  hot  and  cold  douche  (2 
quarts  each)  have  been  beneficial.  4. 
Renal  secretion:  in  ten  minutes  irriga- 
tion at  the  higher  temperatures,  espe- 
cially 110°  or  120°  F.,  stimulates  the 
kidneys  to  secretion  by  the  heat  and  by 
the  stimulating  effect  on  the  circulation, 
also  by  the  heated  blood  flowing  through 
the  organs.  In  twenty  minutes  irriga- 
tion at  110°  or  120°  F.  causes  excretion 
from  the  kidneys  actually  ,  through  ab- 
sorption from  the  intestines. 

If  it  is  desired  to  increase  renal  secre- 
tion without  increasing  pulse-tension  or 
temperature,  one  should  irrigate  at  100° 
to  104°  F.,  and  at  105°  to  108°  F.  if 
moderate  increase  is  not  objectionable. 
Intestinal  absorption  from  the  large  in- 
testine occurs  in  twenty  minutes. 

Saline  irrigation  is  an  excellent  remedy 
in  acute  ursemic  suppression  or  in  cases 
of  renal  insufficiency.  Cold  irrigation 
practically  inhibits  intestinal  absorption, 
on  account  of  the  effect  on  the  circula- 
tion at  the  end  of  twenty  to  twenty-five 
minutes,  and  therefore  should  be  abso- 
lutely contra-indicated  in  renal  disease, 
as  well  as  the  use  of  cold  enemata.  R. 
C.  Kemp  (N.  Y.  Med.  Jour.,  No.  1000,  p. 
141,  '98). 

Intestinal  antiseptics  may  also  be 
given  by  the  month  with  advantage. 
Creasote  may  be  administered  in  emul- 
sion, in  milk,  or  in  wine,  in  doses  of  from 
1  to  5  minims  every  three  hours,  salol  in 
doses  of  5  grains,  betanaphthol  in  doses 
of  from  2  1/2  to  5  grains. 

Local  or  general  antisepsis  of  the 
gastro-intestinal  tract  by  means  of 
medicaments  of  the  aromatic  series 
(benzonaphthol,  naphthol,  naphthalin, 
salol)  is  in  reality  impossible.  These 
substances  do  not  necessarily  break  up 
in  the  alimentary  canal,  but  they  may 
accumulate  or  be  eliminated  without 
undergoing  any  decomposition,  Bardet 
(Bull,  et  Mem.  Soc.  de  Therap.,  Nov.  27, 
'95). 

Salol  is  of  considerable  power  in  in- 
testinal indigestion  (pain,  flatulence, 
and  diarrhoea)  ;  2-grain  doses  of  salol 
every  hour  rapidly  relieve  the  symp- 


toms. Milk  diet  is  the  best  for  those 
suffering  from  excessive  intestinal  pu- 
trefaction,— preferably,  however,  mixed 
with  some  carbohydrates  and  a  little 
meat.  Peas  and  beans,  oatmeal,  whole 
wheat,  Indian  meal,  etc.,  must  be  ex- 
cluded. Rice  or  farina  may  be  allowed 
if  well  cooked.  Eggs,  if  soft  boiled,  are 
well  borne.  A  pure  meat  diet  often 
brings  relief  from  the  symptoms,  if  per- 
sisted in  for  a  few  days.  Fats,  as  a  rule, 
do  no  harm.  Physical  overfatigue  should 
be  avoided.  Herter  and  Smith  (N.  Y. 
Med.  Jour.,  July  13,  20,  '95). 

Literature  of  '96-'97-'98. 

Monnet's  saccharin  No.  3,  a  saccharin- 
ate  of  sodium,  containing  90  per  cent, 
of  pure  saccharin,  given  in  doses  of  from 
15  to  30  grains  once  daily  about  two 
hours  before  the  principal  meal,  must 
take  rank  among  the  best  intestinal 
antiseptics.  Descheemaeker  (Echo  Med. 
du  Nord,  April  10,  '98). 

The  salts  of  bismuth  may  also  be  em- 
ployed, the  subnitrate  or  the  subcarbon- 
ate  in  doses  of  from  10  to  30  grains;  the 
salicylate  or  the  subgallate  in  somewhat 
smaller  doses. 

Ulcerative  colitis  cured  by  means  of 
Carlsbad  salts,  intestinal  antiseptics, 
and  bismuth.  Anderson  (Med.  Review, 
June  23,  '94). 

A  pill  of  silver  oxide,  1/6  grain,  and 
extract  of  belladonna,  l/4  grain,  after 
each  meal,  often  acts  admirably. 

Literature  of  '96-'97-'98. 

Use  of  tannalbin  in  cases  of  acute  and 
chronic  intestinal  catarrh,  and  also  in 
tubercular  diarrhoea  strongly  advocated. 

Tannalbin  is  a  brown,  tasteless  powder, 
containing  about  50  per  cent,  of  tannic 
acid.  It  is  insoluble  in  the  mouth  and 
stomach,  but  on  meeting  with  the  alka- 
line secretions  of  the  intestines  it  is 
resolved  into  its  original  elements,  tan- 
nin and  albumin. 

The  dose  for  children  varies  from  4  to 
8  grains.  Vierordt  (Dent.  mod.  Woch., 
No.  25,  '90). 

Ichthyol  strongly  recommended  in 
intestinal  disorders,  particularly  those 


INTESTINES.  COLITIS, 


MUCOUS.  SYMPTOMS. 


153 


which  accompany  affections  of  the 
genito-urinary  tract  in  women.  The 
dosage  is  4  or  5  grains  a  day,  prefer- 
ably in  keratin-coated  pills,  which  are 
believed  to  pass  through  the  stomach 
undissolved.  The  medicine  is  best  given 
some  little  time  after  meals.  Good  re- 
sults obtained  in  cases  of  diarrhoea.  The 
best  results  were  in  cases  of  rebellious 
constipation.  Guintzburg  (La  Med. 
Mod.,  May  13,  '96). 

Pill  of  1 V2  grains  of  ichthyol  every 
hour  or  two  recommended  in  all  severe 
cases  of  acute  intestinal  catarrh,  also  in 
all  cases  of  chronic  catarrh  of  the  rectum 
and  haemorrhoids  in  which  there  is  a 
great  tendency  to  tympanites  with  foul 
evacuations.  This  treatment  is  very 
efficacious.  Lange  (Allg.  med.  Central - 
Zeit.,  No.  3,  '97). 

Colitis,  Mucous. 

Synonyms.  —  Membranous  enteritis; 
mucous  colic;  tubular  diarrhoea. 

Symptoms. — There  occurs  occasion- 
ally in  hysterical  women  and  neuras- 
thenic and  hypochondriacal  men  a  con- 
dition characterized  by  the  discharge 
from  the  bowel,  from  time  to  time,  of 
membranous  or  tube-like  material,  in 
conjunction  with  abdominal  pain  that 
may  reach  a  high  grade  of  intensity. 
Apart  from  the  paroxysms,  the  bowels  are 
often  constipated;  sometimes  they  are 
loose;  they  are  rarely  regular.  The  stools 
usually  contain  mucus.  The  matters 
expelled  from  the  bowels  consist  prin- 
cipally of  mucus,  although  at  times 
fibrinous  and  cellular  elements  have  been 
found.  They  sometimes  resemble  and 
may  readily  be  mistaken  for  sheets  or 
casts  of  the  bowel.  It  is  believed  that 
they  are  derived  from  the  large  intes- 
tine. Sometimes  they  appear  in  strings 
or  shreds.  They  are  believed  to  be  the 
product  of  an  abnormal  secretion  of  the 
mucous  glands  of  the  bowel. 

Abdominal  pains  regarded  as  the  most 
prominent  symptom  in  membranous  co- 
litis.   These  pains,  which  often  precede 


the  evacuations  by  some  hours,  are  fre- 
quently localized  in  the  left  side  of  the 
abdomen  and  follow  the  course  of  the 
descending  colon  and  of  the  sigmoid 
flexure.  The  pains  may  become  general- 
ized or  may  be  most  decided  near  the 
transverse  colon,  or,  at  other  times,  near 
the  csecum,  generally  ceasing  after  the 
evacuations,  though  the  abdomen  re- 
mains very  sensitive.  Besides  these 
spontaneous  pains  there  is  pain  upon 
abdominal  palpation  in  different  portions 
of  the  large  intestine  and  particularly 
the  region  of  the  sigmoid  flexure.  In 
such  cases  the  pain  is  at  its  height  in 
the  entire  left  iliac  fossa.  Touvenaint 
(Revue  Inter,  de  Med.  et  de  Chir.,  July 
25,  '95). 

Membranous  enteritis  is  not  inflam- 
mation, either  acute  or  chronic.  It  is  a 
secretory  neurosis  affecting  generally 
the  mucous  follicles  of  the  colon  and 
their  regulating  nerves,  but  sometimes 
involving  the  corresponding  elements  of 
the  small  intestine,  bladder,  uterus,  and 
vagina.  There  are  correlated  sensory, 
vasomotor,  and  motor  disturbances.  It 
constitutes  a  comparatively  rare  local 
manifestation  of  a  general  neurosis, 
usually  hysteria  or  neurasthenia.  Glent- 
worth  R.  Butler  (N.  Y.  Med.  Jour.,  Dec. 
28,  '95). 

Literature  of  '96-'97-'98. 

Case  of  intestinal  calculi  in  a  young 
woman  of  31  years,  arthritic  and  neu- 
rotic, who  had  suffered  for  six  years  from 
digestive  disorders  in  the  form  of  flat- 
ulent dyspepsia,  with  dilatation  of  the 
stomach.  The  symptoms  of  muco-mem- 
branous  enteritis  intervened,  with  sharp 
abdominal  pain,  tenderness  along  the 
course  of  the  colon,  and  obstinate  con- 
stipation. After  passing  a  large  amount 
of  muco-membranous  material  over  a 
period  of  six  or  seven  months  the  patient 
began  to  notice  small  stones  in  the  pass- 
ages. Most  of  these  stones  were  about 
the  size  of  orange-seeds,  the  largest  as 
big  as  a  nut,  and  their  discharge  lasted 
two  or  three  weeks.  The  concretions 
were  of  a  yellowish-white  color,  and  very 
friable,  some  of  them  presenting  conical 
elevations  on  their  surfaces,  others 
smooth.     They    were    homogeneous  on 


INTESTINES.  COLITIS, 


MUCOUS.  ETIOLOGY. 


section,  and  did  not  contain  any  central 
nucleus.  Chemical  examination  showed 
the  stones  to  be  composed  principally  of 
carbonate  of  lime  and  phosphates  of 
magnesia,  with  a  small  amount  of  or- 
ganic matter,  iron,  and  water.  Mongour 
(Comptes-Rendus  de  la  Soc.  de  Biol., 
Feb.  28,  '96). 

Intestinal  gravel  is  always  associated 
with  membranous  colitis.  Dieulafoy 
(Acad,  de  Med.,  Mar.  9,  '97). 

Etiology. — The  attacks  are  induced, 
as  a  rule,  by  emotional  disturbances  and 
errors  in  diet,  and  they  recur  with  vary- 
ing frequency,  lasting  from  a  day  or  two 
to  a  couple  of  weeks. 

Literature  of  '96-'97-'98. 

Membranous  enteritis  has  been  found 
to  depend  on  the  presence  of  larvae  in 
the  intestinal  canal.  Henschen  (Wiener 
klin.  Rund.,  No.  33,  '96). 

Membranous  colitis  considered  a  symp- 
tom of  enteroptosis,  and  is  due  to  func- 
tional disturbance  of  the  liver.  Hepa- 
toptosis  leads  to  altered  vascular  tension 
in  the  liver,  and  so  to  a  diminished  se- 
cretion from  mucous  membrane  of  the 
intestine  and  precipitation  of  the  mucin 
by  the  acids  in  the  intestine.  The  author 
is  in  favor  of  a  meat  diet  and  saline 
purges.  Glenard  (Acad,  de  Med.,  Apr. 
20,  '97). 

Membranous  colitis  is  a  functional 
neurosis  and  is  an  intestinal  manifesta- 
tion of  neurasthenia.  The  proper  treat- 
ment is  that  of  nerve-prostration.  Men- 
delson  (Med.  Record,  Jan.  30,  '97). 

Membranous  colitis  regarded  as  an 
hypersecretion  of  mucus  in  women  of  a 
neuro-arthritic  type  who  suffer  from 
enteroptosis.  The  constipation  is  to  be 
treated  by  giving  copious  enemata  and 
castor-oil.  Intestinal  antiseptics,  such 
as  naphthol,  resorcin,  and  salicylate  of 
bismuth,  should  be  given.  Mathieu 
(Semaine  Med.,  p.  226,  '97). 

Secretion-neurosis  is  of  neurotic  origin 
and  course.  Both  secretion-neurosis  and 
enteritis  may  co-exist.  Secretion-neu- 
rosis of  the  colon  occurs  chiefly  in  neu- 
rotic females  (80  per  cent.).  It  is  closely 
associated  with  genital  disease  and  is 
frequently    preceded    by  constipation. 


The  continuation  of  the  disease  is  partly 
due  to  an  irritable,  vicious  habit  of  ex- 
cessive epithelial  activity.  The  disease 
is  characterized  by  colicky  pains,  with 
the  evacuation  of  mucous  masses;  it  is 
not  fatal  and  is  variable  and  erratic  in 
the  number  of  attacks,  with  an  indefinite 
prognosis.  Chemically  the  evacuations 
consist  of  mucin  and  an  albuminous  sub- 
stance. Microscopically  there  are  seen 
hyaline  bodies,  cylindrical  epithelium, 
cholesterin  crystals,  triple  phosphates, 
round  cells,  various  kinds  of  micro-organ- 
isms, and  pigment.  Secretion-neurosis  of 
the  colon  is  comparable  to  the  secretion- 
neurosis  of  the  endometrium  (membra- 
nous dysmenorrhcea)  or  bronchial  croup 
and  appears  to  be  limited  chiefly  to  the 
part  of  the  colon  supplied  by  the  inferior 
mesenteric  ganglion:  i.e.,  to  the  faecal 
reservoir  (the  left  half  of  the  transverse 
colon,  the  descending  colon,  the  sigmoid 
and  the  rectum).  Bryan  Robinson 
(Mathews's  Jour,  of  Rectal  and  Gastro- 
Int.  Dis.,  Jan.,  '98). 

They  may  be  attended  with  acute  out- 
breaks of  hysteria,  hypochondriasis,  or 
melancholia. 

The  nervous  complications  of  muco- 
membranous  enteritis  are  most  varied, 
among  those  noted  being  dyspnoea, 
pseudo-angina  pectoris,  generalized  trem- 
bling -during  digestion,  inaptitude  for 
work,  headache,  aphasia,  temporary  am- 
nesia, infantile  convulsions,  coma,  etc. 
A.  Mathieu  (Gaz.  des  Hop.,  Oct.  27,  '94). 

Two  cases  of  membranous  colitis  ob- 
served presenting  hysterical — one  epilep- 
tic and  the  other  choreic — symptoms 
dependent  on  the  condition  of  the  in- 
testine and  disappearing  as  the  state  of 
the  latter  improved.  F.  Cantru  (La  Med. 
Mod.,  Jan.  12,  '95). 

Prognosis. — The  condition  is  often  an 
obstinate  one  and  extremely  unyielding 
to  treatment. 

The  prognosis  of  membranous  colitis 
is  not  generally  grave,  especially  when 
the  attacks  are  not  very  intense  or  when 
they  occur  at  short  intervals.  However, 
the  disease  constitutes  a  serious  compli- 
cation, for  it  contributes  greatly  to  pro- 
duce cachexia  and  it  is  very  rebellious 


INTESTINES.    COLITIS,  MUCOUS.    TREATMENT.  TUMORS. 


155 


to  treatment.  Touvenaint  (Revue  Inter, 
de  Med.  et  de  Chir.,  July  25,  '95). 

Prognosis  of  membranous  colitis  not 
especially  favorable,  since  there  is  little 
prospect  of  ultimate  cure  unless  a  radical 
change  can  be  effected  in  the  circum- 
stances and  surroundings  of  the  patient. 
O.  D.  Doane  (Med.  Sentinel,  Sept.,  '95). 

Membranous  enteritis  does  not  yield 
to  treatment  in  the  majority  of  cases.  It 
may  improve  while  the  patient  is  under 
treatment,  but  it  also  improves  for  a 
time  without  any  treatment  at  all.  It 
is  not  a  fatal  complaint.  People  may 
have  it  for  years  and  pass  vast  quanti- 
ties of  mucus,  and  yet  look  fairly  well 
at  the  end  of  that  time.  It  often  im- 
proves temporarily,  and  then  returns 
after  a  short  or  long  interval.  In  some 
cases  it  recurs  at  regular  times  and  con- 
tinues to  do  so  every  month  or  so  for 
years.  It  almost  always  occurs  in  dys- 
peptic and  somewhat  neurotic  patients. 
It  is  essentially  a  disease  which  is  af- 
fected by  the  mental  state  of  the  patient. 
In  some  cases  worry  always  brings  on  an 
attack,  while  freedom  from  care  is  almost 
essential  to  its  cure.  C.  P.  Crouch 
(Bristol  Medico-Chir.  Jour.,  Mar.,  '95). 

Treatment. — Treatment  mnst  be  di- 
rected to  the  underlying  state,  although 
the  condition  of  the  digestive  tract  must 
not  be  ignored.  Nervines,  tonics,  intes- 
tinal antiseptics,  and  supporting  meas- 
ures generally  are  the  agents  indicated. 
Asafcetida,  sumbul,  valerian,  iron, 
strychnine,  hydrogen  dioxide,  creasote, 
guaiacol,  singly  or  in  varying  combina- 
tion, are  sometimes  useful.  The  best  re- 
sults are  to  be  expected  from  rest  and  a 
milk  diet,  with  massage  and  electricity, 
and  later  forced  feeding  and  a  gradual 
return  to  the  ordinary  mode  of  life. 

In  the  treatment  of  membranous  coli- 
tis rest  in  bed  is  essential,  with  ab- 
dominal friction  to  soothe  the  pains, 
using  a  soothing  liniment  or  camphor- 
ated oil  to  which  laudanum  has  been 
added.  If  the  pain  is  very  acute,  opiates 
may  be  given  in  small  doses,  either  as  a 
potion  or  an  enema.  Letcheff  recom- 
mended the  use  of  copious  irrigations 


with  hot  solutions  of  nitrate  of  silver 
in  the  proportion  of  1  to  2000,  or  even 
1  to  1000.  Touvenaint  (Revue  Inter,  de 
Med.  et  de  Chir.,  July  25,  '95). 

Tumors  of  the  Caecum,  the  Colon,  and 
the  Duodenum. 

New  growths  in  the  intestinal  tract  are 
much  more  common  in  the  large  than  in 
the  small  division.  Of  the  large  intes- 
tine the  rectum  is  most  frequently  at- 
tacked; then  in  the  order  of  frequency 
the  sigmoid  flexure,  the  caecum,  and  the 
remainder  of  the  colon.  Of  the  small  in- 
testine the  ileum  seems  to  suffer  most 
commonly,  the  duodenum  next  in  fre- 
quency, and  the  jejunum  least.  The 
growth  is  usually  primary;  less  com- 
monly it  arises  by  extension  from  con- 
tiguous disease.  Metastasis  to  other  or- 
gans is  frequent,  and  rather  the  more  so 
from  the  small  than  from  the  large 
bowel.  The  involvement  of  adjacent 
structures  and  organs  also  is  common. 

Case  of  colloid  cancer  of  the  transverse 
colon,  in  which  the  tumor  had  infiltrated 
the  neighboring  tissues,  become  attached 
to  the  abdominal  wall,  and  formed  a 
large,  abscess-like  cavity;  into  this 
opened  the  transverse  colon,  a  loop  of 
small  intestine,  and  also  the  lower  end 
of  the  stomach.  The  man  died  of  ex- 
haustion. No  operation  was  performed. 
Dreschfeld  (Brit.  Med.  Jour.,  Apr.  30, 
'92). 

Case  of  a  woman  from  whom  two 
primary  cancers  the  size  of  a  man's  fist 
had  been  removed  from  the  large  intes- 
tine by  Landau.  Their  cancerous  nature 
having  been  ascertained  by  Virchow,  the 
patient  was  kept  under  observation,  and 
at  her  death,  a  year  after  operation,  the 
diagnosis  of  primary  cancer  of  the  large 
intestine  was  verified,  metastases  being 
found  in  the  peritoneum,  retroperitoneal 
glands,  left  pleura,  and  abdominal  tis- 
sues. The  primary  tumor  had  sprung 
from  the  endothelium  of  the  lymphatic 
vessel  and  connective-tissue  cells,  thus 
belonging  to  the  class  of  endothelial 
cancer  of  the  serous  membranes,  very 


♦ 


156 


INTESTINES.    TUMORS.  TREATMENT. 


rare  in  the  peritoneum.    Ludwig  Pick 

(La  Med.  Mod.,  Mar.  27,  '95). 
The  most  usual  variety  of  neoplasm 
is  carcinoma  and  especially  of  the  cylin- 
der-cell type;  epitheliomata  are  less  com- 
mon. Sarcomata  are  rare.  The  disease 
occurs  a  little  more  commonly  in  males 
than  in  females  and  rather  earlier  in  life 
than  malignant  disease  elsewhere,  a 
larger  number  of  cases  occurring  before 
the  age  of  30  than  when  the  disease  is 
situated  in  other  parts  of  the  body.  The 
duration  of  malignant  disease  of  the 
bowel  averages  from  six  to  twenty-four 
months. 

Symptoms. — Among  the  most  con- 
spicuous symptoms  of  malignant  disease 
of  the  intestine  are  anaemia,  cachexia, 
wasting,  pain,  indications  of  intestinal 
obstruction,  fever,  and  the  presence 
usually  of  a  tumor  yielding  dullness  on 
percussion.  When  ulceration  occurs  the 
stools  will  contain  blood,  pus,  and  per- 
haps fragments  of  the  new  growth.  The 
associating  symptoms  will  necessarily 
vary  somewhat  with  the  situation  of  the 
growth. 

Methods  to  be  followed  in  examin- 
ing intra-abdominal  tumors:  — 

Tumors  through  which  gases  may  be 
detected  by  gurgling  indicate  either  an 
involvement  of  the  bowel  in  the  tumor 
or  pressure  of  the  growth  on  the  bowel, 
with  adhesions  to  the  same.  If  this 
symptom  is  coupled  with  a  history  of  a 
pyloric  cancer  or  a  csecal  growth,  it  is 
confirmatory  in  its  indications.  Some 
growths  have  a  disposition  to  change 
position,  but  all  growths  have  one  or 
more  attachments,  and  it  is  safe  to  infer 
that  this  attachment  is  to  the  site  at 
which  the  neoplasm  had  its  beginning, 
its  movements  being  only  around  an  arc 
of  a  circle.  Adhesions  may  prevent  a 
growth  from  moving,  or  anchor  a  tumor 
in  a  locality  far  from  its  original  point 
of  starting,  and  here  the  history  of  the 
inflammatory  attacks  and  pain  aid  in 
the  diagnosis.  The  character  of  the  pain 
and  the  amount  and  area  of  tenderness 
are  of  great  assistance.    The  withdrawal 


of  free  fluid  from  the  peritoneum  often 
shows  the  presence  of  a  tumor  before 
undetected.  A.  H.  Cordier  (N.  Y.  Med. 
Jour.,  Oct.  26,  '95). 

Carcinoma  of  the  duodenum  is  rare. 

Among  the  records  of  about  18,000 
autopsies  at  Guy's  there  are  reports  of 
10  cases  of  primary  malignant  growth  of 
the  duodenum:  4  carcinomata  and  6 
sarcomata.  Together  with  collected 
cases,  a  total  of  22  primary  malignant 
growths  are  described:  13  carcinomata 
and  9  sarcomata.  Secondary  deposits  of 
malignant  growths  are  very  rarely  ob- 
served in  the  duodenum.  Perry  and 
Shaw  (Guy's  Hosp.  Reports,  vol.  1,  p. 
171). 

It  may  be  situated  close  to  the  pylorus 
or  in  the  region  surrounding  the  en- 
trance of  the  choledoch-  and  pancreatic 
ducts  or  close  to  the  jejunum,  and  the 
symptoms  will  vary  accordingly.  In 
addition  to  other  manifestations  there 
are  anorexia,  nausea,  vomiting,  and  pain. 
When  a  tumor  becomes  palpable  it  will 
be  found  in  the  right  upper  quadrant  of 
the  abdomen,  and  it  is,  as  a  rule,  fixed, 
and  little,  if  at  all,  mobile  upon  manipu- 
lation or  with  the  movements  of  respira- 
tion. Pain,  when  present,  has  a  corre- 
sponding localization,  but  it  is  likely  to 
occur  at  a  later  period  after  the  ingestion 
of  food  than  that  of  malignant  disease  of 
the  stomach.  When  the  first  or  pyloric 
portion  of  the  duodenum  is  the  seat  of 
the  new  growth  the  symptoms  may  simu- 
late those  of  pyloric  obstruction,  among 
the  most  distinctive  of  which  are  dilata- 
tion of  the  stomach,  with  vomiting  peri- 
odically of  vast  amounts  of  fluid  and 
partly-disintegrated  food,  some  of  which 
may  have  been  ingested  days  before.  If 
the  neoplasm  develop  close  to  the  point 
of  entrance  of  the  biliary  and  pancreatic 
ducts  into  the  duodenum, — i.e.,  in  the 
ampullar  portion, — jaundice  will  almost 
certainly  ho  a  symptom  in  consequence 
of  obstruction  to  the  flow  of  bile.   If  the 


INTESTINES.    TUMORS.  TREATMENT. 


1ST 


disease  be  situated  beyond  this  point, — 
that  is,  in  the  jejunal  portion, — the 
vomited  material  will  contain  bile  and 
intestinal  matters. 

Primary  cancer  of  the  duodenum  has, 
in  the  great  majority  of  cases,  an  an- 
nular form,  and  thus  most  frequently 
produces  stenosis,  the  stenotic  symptoms 
varying  according  to  the  level  at  which 
the  growth  occurs.  Above  the  ampulla 
of  Vater  the  neoplasm  develops  in  the 
first  portion  of  the  duodenum  and  pre- 
sents a  symptomatology  almost  identical 
to  that  of  pyloric  cancer.  In  that  below 
the  ampulla,  besides  the  symptoms  ac- 
companying stenosis  of  the  pylorus, 
there  are  signs  indicating  a  reflux  of 
bile  and  pancreatic  juice  into  the  stom- 
ach, while  in  that  developing  about  the 
ampulla  the  symptoms  approach  more  or 
less  one  or  the  other  of  the  above  forms. 
When  diagnosis  is  impossible,  explora- 
tory laparotomy  constitutes  the  first 
measure  necessary  for  surgical  interven- 
tion, which,  however,  in  the  greater 
number  of  instances,  cannot  be  more 
than  palliative.  Pic  (Revue  de  Med., 
Jan.,  '95). 

Carcinoma  of  the  caecum  is  commonly 
attended  with  symptoms  resembling 
those  that  have  been  more  fully  detailed 
in  the  consideration  of  typhlitis:  pain  in 
the  right  iliac  fossa,  with  constipation 
(perhaps  diarrhoea),  tympanitis,  im- 
paired appetite,  coated  tongue,  bad  taste, 
nausea,  and  vomiting. 

Carcinoma  of  the  caecum  is  not  rarely 
a  most  chronic  condition  that  may  exist 
for  years  without  giving  rise  to  symp- 
toms other  than  slight  constipation  and 
the  presence  of  a  tumor.  Matlakowski 
(Deut.  Zeit.  f.  Chir.,  B.  33,  H.  4,  5,  '92). 

The  ileo-csecal  region  is  a  point  of 
predilection  for  the  development  of  ma- 
lignant tumors,  mostly  in  the  form  of 
carcinoma  and  local  intestinal  tubercu- 
losis. The  lumen  of  the  gut  is  dimin- 
ished and  the  glands  much  enlarged. 

The  onset  of  malignant  disease  is  very 
insidious,  the  symptoms  being  usually 
those  of  typhlitis  and  coprostasis.  As 
regards  treatment,  resection  and  reunion 
of  the  divided  parts  are  necessary,  but 


symptoms  of  acute  obstructions  are 
contra-indications.  Simple  enterostomy 
is  here  called  for,  with  resection  later 
on.  The  extent  of  the  tumor  and  ad- 
vanced cachexia  are  also  contra-indica- 
tions. Korte  (Deut.  Zeit.  f.  Chir.,  B.  40, 
H.  5,  6,  '95). 

The  tumor  that  develops,  with  dull- 
ness on  percussion,  will  be  found  in  the 
right  lower  quadrant  of  the  abdomen, 
though  capable  of  a  certain  range  of 
movement.  As  obstruction  becomes 
marked,  attacks  of  colic  will  occur,  in 
consequence  of  the  augmented  expulsive 
efforts  of  the  proximal  bowel,  which  at 
first  undergoes  hypertrophy,  with  subse- 
quent atrophy  and  atony  and  dilatation, 
while  the  distal  intestine  becomes  col- 
lapsed and  empty. 

The  symptoms  of  carcinoma  of  the 
colon  differ  principally  in  localization 
from  those  attributable  to  like  disease  in 
the  caecum. 

Case  of  primary  cancer  of  the  colon 
reported  in  which  the  digestive  process 
continued  normal  without  haemorrhage. 
Matiguor  (Jour,  de  Med.  de  Bordeaux, 
Dec.  24,  '90). 

The  greater  mobility  of  the  large 
bowel,  however,  permits  of  freer  move- 
ment on  the  part  of  the  tumor,  with 
greater  displacement  and  greater  vari- 
ability in  situation.  The  closer  the 
growth  to  the  rectum,  the  more  pro- 
nounced the  change  in  the  conformation 
of  the  stools,  which  may  become  charac- 
teristically narrow  in  caliber  or  band- 
shaped  or  ribbon-shaped. 

Literature  of  '96-'97-'98. 

Case  of  a  man  on  Avhom  the  author  had 
operated  in  1894,  resecting  six  inches 
of  the  transverse  colon,  which  was 
the  seat  of  stenosing  adenocarcinoma, 
which  had  been  present  for  at  least  a 
year.  The  stenosis  had  become  so  great 
that  only  a  small-sized  lead-pencil  could 
be  passed  through  the  stricture  at  the 
time  the  specimen  was  removed.  There 


158 


INTESTINES.    TUMORS.  DIAGNOSIS. 


was  great  emaciation  and  pain.  Anas- 
tomosis was  made  with  a  Murphy  button 
of  enormous  size,  which  was  passed  on 
the  eighteenth  day.  The  man  gained 
thirty  pounds  in  weight  in  a  short  time, 
and  has  remained  in  perfect  health  since. 
There  are  no  signs  of  recurrence.  A 
number  of  nodules  in  the  mesentery  had 
been  removed,  but  there  were  innumer- 
able small  ones  which  had  to  be  left. 
Howard  Lilienthal  (Annals  of  Surg., 
May,  '96). 

Under  favorable  conditions  it  may  be 
possible  to  recognize  malignant  disease 
of  the  sigmoid  flexnre  by  means  of 
manual  exploration  through  the  rectum 
or  with  the  aid  of  the  sigmoidoscope. 

Diagnosis. — Carcinoma  of  the  duo- 
denum is  to  be  differentiated  from  car- 
cinoma and  ulcer  of  the  stomach,  from 
duodenal  ulcer,  from  gall-stones,  and 
from  new  growths  or  enlarged  glands 
compressing  the  duodenum  from  with- 
out. From  the  two  forms  of  ulceration 
named,  it  differs  in  the  progressiveness 
of  character,  the  shorter  period  of  dura- 
tion, the  development  of  cachexia,  the 
greater  wasting,  the  presence  of  a  tumor, 
a  diminution  in  hydrochloric  acid  of  the 
gastric  juice,  or  perhaps  its  absence,  and 
the  smaller  frequency  of  haematemesis 
(the  blood  presenting  the  characteristic 
coffee-grounds  appearance).  The  differ- 
entiation from  malignant  disease  of  the 
stomach  will  have  to  be  based  upon  the 
situation  of  the  palpable  tumor  and  its 
degree  of  mobility,  the  frequency  and 
the  time  of  vomiting,  and  the  situation 
and  the  time  of  occurrence  of  the  pain. 
Gall-stones  may  occasion  symptoms 
closely  resembling  those  of  malignant 
disease  of  the  duodenum,  but  they  are 
unattended  with  cachexia,  they  differ  in 
course  and  duration,  and  the  tumor  to 
which  they  give  rise  differs  in  its  general 
physical  characteristics  from  that  due 
to  malignant  disease  of  the  duodenum. 
The  differentiation  from  new  growths  or 


enlarged  glands  compressing  the  duode- 
num from  without  depend  largely  upon 
the  recognition  of  the  conditions  to 
which  such  processes  are  usually  second- 
ary. Such  growths  and  glands  are  un- 
attended with  the  pain,  digestive  de- 
rangement and  vomiting  so  common 
with  malignant  disease  of  the  duodenum. 

Malignant  disease  of  the  large  intes- 
tine is  to  be  distinguished  from  faecal 
accumulation,  peritonitic  adhesions,  and 
the  presence  of  foreign  bodies  in  the  in- 
testine. All  of  these  are  unattended  with 
cachexia  and  wasting.  In  cases  of  faecal 
accumulation  there  is  a  history  of  long- 
standing constipation,  with  the  correc- 
tion of  which  any  tumor  that  was  pres- 
ent disappears.  When  peritonitic  ad- 
hesions are  present  inquiry  may  elicit  the 
previous  existence  of  peritonitis.  Among 
foreign  bodies  occasionally  found  in  the 
bowel  are  gall-stones,  enteroliths,  and 
possibly  detached  pedunculated  polypoid 
growths. 

Enterolith  weighing  three  hundred 
and  seventy-five  grains;  length,  two  and 
one-fourth  inches;  circumference,  one 
and  one-fourth  inches;  diameter,  one 
inch,  removed  from  ileum  by  longitudinal 
incision.  Death  occurred  the  following 
day  of  pulmonary  oedema.  Perry  (Al- 
bany Med.  Annals,  June  20,  '88). 

Case  of  impaction  of  the  rectum  with 
water-melon  seeds,  one  quart  of  which 
were  removed  by  injections.  Ricketts 
(Cincinnati  Lancet-Clinic,  Sept.  22,  '88). 

Case  of  large  faecal  accumulation  oc- 
curring in  a  girl,  aged  13  years,  observed. 
A  rapidly-growing  abdominal  tumor  was 
not  diminished  by  purgatives,  and,  as 
the  patient  was  sinking,  an  exploratory 
laparotomy  was  done.  On  opening  the 
abdomen  the  tumor  was  found  to  be  a 
fa?cal  mass  in  the  caxum  and  colon. 
Nothing  further  was  done,  as  the  bowels 
began  to  act.  and  in  six  days  the  tumor 
had  entirely  disappeared.  Worrall  (Med. 
Rec.,  June  30,  '88). 

Case  showing  the  diagnostic  association 
between  cancer  of  the  colon  and  floating 


Nothing  fcil<e  it  Ever  Written. 


J(J5T  PUSLLSHEb. 


Tie  Plpcian's  Wife; 

AND  THE 

THINGS  THAT  PERTAIN  TO  HER  LIFE. 


BY 


Ellen  M.  Firebauqh. 


Gracefully  written,  full  of  genuine  humor,  and 
true  to  nature,  this  little  volume  is  a  treasure  that 
will  lighten  and  brighten  many  an  hour  of  care 
and  worry. 

The  author,  the  wife  of  one  of  Illinois'  well- 
known  physicians,  dedicates  her  book  to  Mrs 
Frances  Hodgson  Burnett,  who  has  accepted  the 
compliment  in  a  charming  and  graceful  letter  ex- 
pressing her  appreciation. 

The  Publishers  are  content,  without  further 
comment  of  their  own,  to  let  others— Readers  and 
Critics,  Press  and  Public— express  their  opinion 
concerning  this  book. 


Mrs.  Frances  Hodgson  Bur- 
nett, one  of  the  most  widely-read 
and  greatly-loved  women  writers 
of  this  age,  and  herself  a  phy- 
sician's wife,  writes  :  "It  is  such' a 
real  record.  I  am  sure  you  will 
find  you  have  touched  chords 
which  will  find  echoes  in  the 
hearts  of  numberless  physicians' 
wives." 


Dr.  H.  M.  Lyman,  Professor  of 
Principles  and  Practice  of  Medi- 
cine in  Rush  Medical  College, 
Chicago,  writes:  "'The  Physi- 
cian's Wife'  is  a  very  readable 
volume.  My  wife  is  now  at  it 
with  a  great  deal  of  relish." 


Dr.  Willis  P.  King,  of  Kansas 
City,  says:  "I  have  enjoyed  the 
book  very  much.   It  is  well  writ- 
fOVER.l 


ten,  the  style  is  good,— showing  a 
cultivated,  original  mind,  a  keen 
observation  on  the  part  of  the 
author,  a  good  generalizer,  and 
the  points  are  well  taken." 

Dr.  Dan  Milliken,  of  Hamilton, 
Ohio,  writes:  "Mrs.  Firebaugh 
has  much  humor  and  a  rare  gift  of 
expression.  The  book  has  given 
me  a  great  deal  of  pleasure,  and, 
more  than  that,  it  has  pleased 
members  of  my  family  who  have 
no  near  interest  in  the  author." 

Dr.  C.  B.  Johnson,  of  Cham- 
paign,  Ills.,  says:  "I  don't  know 
when  I  have  had  more  genuine 
pleasure  than  came  to  me  from 
reading  this  book.  I  was  sorry 
when  I  came  to  the  end.'' 

Dr.  J.  W.  Rutledge,  of  Minne- 
apolis, writes :  "Mrs.  Firebaugh 
has  portrayed  in  a  happy  vein  of 
humor  and  truthfulness  the  part 
of  a  physician's  wife  and  the  phy- 
sician himself.  I  hope  it  will  find 
its  way  into  the  hands  of  every 
doctor  in  the  land.  It  will  be 
pleasing  for  the  old  fellows  who 
have  grown  gray  in  the  business 
and  for  those  who  are  beginning,— 
a  pleasant  reminder  not  to  neglect 
that  indispensable  part,  the  better 
half." 

Dr.   John  W.  McCullough, 

Alliston,  Ontario,  writes  :  "  I  am 
glad  to  have  had  the  pleasure  of 
reading  your  splendid  little  book, 
'The  Physician's  Wife,' notwith- 
standing that  it  has  given  my  wife, 
who  is  '  one  of  them,'  a  chance 
to  say,  'It's  exactly  like  you, 
Jack.'  We  all  have  faults,  and 
no  doubt  it  does  us  good  to  be 
occasionally  gently  reminded  of 
them,  as  you  so  very  nicely  do." 

Dr.  Philip  Zenner,  of  Cincin- 
nati, writes:  "I  can  scarcely  speak 
in  high  enough  terms  of  'The 
Physician's  Wife.'   Perhaps  the 


best  I  can  say  is  that  after  picking 
it  up  1  never  put  it  down  again 
except  when  it  was  absolutely 
necessary.  I  read  from  the  first 
word  on  the  fly-leaf  to  the  last 
page,  nor  need  1  say  that  the  book 
is  charming  and  that  every  page 
gave  me  delight." 

From  Medical  Record  :  "  The 

taking  title,  the  chastely  modest 
style,  the  domestic  complexion  of 
the  story,  and  the  spirited  and 
graphic  description  of  life-scenes 
make  it  a  very  entertaining  little 
book.  Mrs.  Firebaugh  appreciates 
all  from  her  wifely  stand-point  and 
tells  it  with  a  sweet  pathos  and 
chaste  humor  which  gives  her 
effort  its  main  charm.  We  visit 
the  doctor's  patients,  we  hear  their 
stories,  appreciate  their  oddities, 
sympathize  with  their  distresses, 
and  become  a  part  of  the  landscape 
as  we  drive  with  him  through 
fresh  country  lanes,  past  fragrant 
woods,  and  over  breezy  hills. 
Many  a  young  bachelor,  in  a  met- 
ropolitan flat,  whose  only  convey- 
ance is  the  crowded  street-car, 
would  gladly  shift  situations  and 
try  his  luck  at  being  the  partner 
of  such  a  better-half." 

From  The  Spirit  of  the  Times : 
"It  is  full  of  good  stories  about 
doctors,  capitally  told,  and  of  good 
advice  to  doctors  and  their  wives, 
sincerely  given.  No  one  can  read 
it  without  seeing  that  every  word 
is,  like  the  illustrations,  drawn 
from  life." 

From  Cincinnati  Lam-et- 
Clinic:  "This  small  volume  of 
185  pages,  admirably  presented  by 
the  publishers,  is  a  most  charming 
book.  It  sparkles  with  wit  and 
humor,  and  touches  of  nature 
illuminate  every  page.  Every 
physician  and  every  physician's 
[  wife  will  find  delightful  reading 
I  here ;  nor  need  one  be  either  the 


.  one  or  the  other  to  find  equal 
pleasure  in  its  perusal." 

From  Medical  Brief:  "She 
has  done  her  work  well,  and  we 
hope  that  every  one  of  our  large 
list  of  physicians  who  has  a  wife 
will  secure  a  copy  for  her,  and  to 
those  who  have  not  it  will  afford 
very  interesting  reading." 

From  American  Medico-Sur- 
gical Bulletin :  "  There  is  an  ever- 
present  vein  of  humor,  quaint  in 
itself  and  charming,  and  many 
amusing  incidents,  well  drawn  and 
true  to  life,  which  evince  the 
author's  knowledge  of  her  sub- 
ject ;  while  her  versatility  and 
power  of  expression  would  lead 
the  casual  reader  to  suppose  them 
to  be  the  mere  creation  of  a  fertile 
brain." 

From  Chicago  Clinical  Re- 
view: "A  nicely  printed  and  at- 
tractive book  to  be  read  by  the 
doctor's  wife,  and  by  the  doctor 
himself,  during  those  moments 
when  all  is  still,  the  flames  upon 
the  hearth  burn  low,  and  the  mind 
is  charmed  into  reverie.  It  is  fre- 
quently lively  and  altogether  en- 
tertaining." 

From  The  Prescription  :  "  It  is 
a  helpful  book,  a  true  book  drawn 
from  an  experience  which  is  worth 
relating,  and  worth  the  publishers 
printing  in  the  handsome  style  that 
the  F.  A.  Davis  Company  have 
done,  and  for  which  they  are 
famous.  We  predict  for  it  a  large 
sale  and  hearty  reception." 

From  Pacific  Record  of  Medi- 
cine and  Surgery :  "  It  is  not 
only  euphonious  in  diction,  truth- 
ful in  narrative,  but  presents 
vividly  to  the  mind's  eye  a  true 
illustration  of  the  trials  and  strug- 
gles of  a  physician's  life.  The 
writer  has  a  genius  that,  culti- 


vated, would  enable  her  husband 
to  dispense  with  the  paltry  pay  of 
the  profession." 

From  Dominion  Medical 
Monthly:  "It  is  worth  reading, 
there  is  so  much  of  common  sense 
and  genuine  heartiness  about  it." 

From  Homoeopathic  Physi- 
cian :  "An  hour  will  not  be 
wasted  spent  with  this  little 
volume." 

From  Medical  Times  and 
Hospital  Gazette,  London,  Eng.  : 
"We  would  recommend  every 
medical  man  to  present  his  wife 
with  a  copy,  and  to  read  it  him- 
self." 

From  The  Sunday  School 
Times:  "The  general  public  as 
well,  having  an  interest  in  what- 
ever concerns  this  universal  family 
friend,  will  find  here  many  profit- 
able hints,  while  enjoying  fully  the 
author's  subtle  humor  and  keen 
insight  into  human  nature." 

From  The  American  Medical 
Journal :  "  The  book  is  re- 
plete with  amusing  incidents,  and 
its  perusal  calls  up  the  reminis- 
cences in  a  doctor's  life.  Every 
doctor  should  read  it,  his  wife 
especially." 

From  Pittsburgh  Medical  Re- 
view: "To  many  it  will  recall 
scenes  of  the  old  homestead  and 
days  of  youthful  home-life,  that, 
in  the  excitement  and  hurry  of 
the  city,  are  'dear  to  the  mind 
when  fond  recollections  present 
them  to  view.' " 

From  North  American  Jour- 
nal of  Homoeopathy:  "It  is  a 
plain,  unassuming,  simple  narra- 
tive, but  there  are  passages  in  it 
that  will  strike  home  to  every  pro- 
fessional reader  and  lead  him  off 
in  most  profound  reverie.  That 
some  of  the  scenes  are  from  life 


cannot  be  doubted ;  in  that  fact  in 
great  part  resides  the  charm  of  the 
book." 

Prom  Southern  California 
Practitioner:  "  It  is  bright,  spark- 
ling, and  true  to  nature.  The 
stories  are  fresh  and,  being  from 
personal  experience,  are  new, 
although  similar  circumstances 
have  probably  occurred  in  the 
lives  of  most  physicians'  wives. 
It  abounds  in  wit  and  humor." 

From  Meyer  Bros.'  Druggist: 

"If  a  pharmacist  is  anxious  for 
some  nice  present  to  send  a  phy- 
sician as  a  token  of  friendship 
(business  or  otherwise),  this  is  just 
the  article  desired. 

From  The  Medical  Summary : 

"We  have  not  the  space  to  pre- 
sent details  of  its  contents ;  but 


suffice  it  to  say,  buy  this  book 
if  you  have  a  wife  :  she  will  un- 
doubtedly enjoy  reading  it ;  if  you 
have  no  wife,  buy  it  anyway." 

From  Pharmaceutical  Era : 
"Her  homely,  simple  recitals  of 
the  trials,  cares,  sorrows,  and  joys 
of  the  wife  of  the  country  prac- 
titioner appeal  strongly  to  the 
sensibilities,  the  frequent  bits  of 
pathos  and  humor  rendering  each 
page  fascinating  and  holding  the 
reader's  attention  to  the  end. 
Doctors  all,  and  their  wives,  too, 
should  read  this  little  work." 

From  The  Union  Signal :  "This  . 
volume  gives,  in  its  humorous  and 
yet  pathetic  pages,  many  a  really 
helpful  glimpse  into  the  life  of 
that  much-tried  and  not  very 
much-noticed  member  of  society, 
the  doctor's  wife." 


Crown  Octavo,  200  Pages,  with  44  Original  Char- 
acter Illustrations  and  a  Frontispiece  Por- 
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ESPECIAL  LIMITED  EDITION.- First  500 
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tractively hound  in  FINE  VELLUM  CLOTH  and  LEATHER. 
Price,  S3. 00  net.  The  Publishers  reserve  the  right  to  increase 
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116 — 99 


INTESTINES.    TUMORS.  DIAGNOSIS. 


159 


kidney.  A  cancer  in  the  middle  part  of 
the  ascending  colon  gave  rise  to  dull 
achings  and  pains,  which  the  patient 
almost  certainly  associated — at  first — 
with  his  kidney;  and  as  the  mass  de- 
veloped the  bowel  became  more  and  more 
loaded  and  distended,  the  lumbar  achings 
increased  on  account  of  pressure  upon  the 
psoas  and  the  lumbar  nerves.  This  pres- 
sure was  especially  felt  by  the  genito- 
crural  branch,  and  the  patient  complained 
of  pain's  shooting  into  the  groin  and  into 
the  region  of  the  cord  and  testis.  Had 
these  symptoms  been  associated  with 
blood  in  the  urine  they  might  have  sug- 
gested the  presence  of  a  renal  calculus, 
but  there  was  no  history  of  hsematuria. 
Edmund  Owen  (Lancet,  Apr.  27,  '95). 

An  inquiry  into  the  history  and  the 
progress  of  the  case  will  soon  remove 
any  doubt  that  may  have  existed. 

Sarcoma  of  the  bowel,  likewise,  is,  in 
the  majority  of  cases,  primary,  and  it 
commonly  gives  rise  to  metastasis.  It 
extends  by  contiguity  and  may  thus  give 
rise  to  the  dilatation  and  rigidity  of  the 
wall  of  the  bowel.  It  also  appears  at  an 
earlier  period  in  life  than  malignant  dis- 
ease elsewhere.  Constitutional  symp- 
toms are  likely  to  develop  before  local 
manifestations.  The  temperature  often 
is  elevated.  There  may  be  constipation 
alternating  with  diarrhoea. 

Case  of  stricture  below  the  ampullae  of 
Vater  caused  by  a  small,  round-celled, 
sarcomatous  deposit  located  in  second 
part  of  the  duodenum.  The  symptoms 
were:  violent  pain  over  the  pyloric 
region,  large  and  frequent  vomitings, 
acid  regurgitations,  and  pain  in  the 
head.  The  stomach  was  much  dilated, 
the  vomited  matter  contained  much  bile, 
and  in  the  contents  of  the  stomach  were 
always  found  a  notable  quantity  of 
hydrochloric  acid  and  bile  and  non- 
digested  food,  especially  amylaceous 
material.  Masius  (Annales  de  la  Soc. 
Medico-Chir.,  June,  '91). 

Literature  of  '96-'97-'98. 

Case  of  a  woman,  aged  32,  who  came 
under  observation  with  attacks  of  pain- 


ful diarrhoea,  and  a  tumor  below  and  to 
the  left  of  the  umbilicus.  Laparotomy 
was  performed,  and  the  tumor  was  then 
found  to  involve  the  jejunum  at  one 
metre's  distance  from  the  duodenum. 
The  portion  of  intestine  was  resected, 
but  the  patient  died  the  next  day. 
The  growth  was  twenty  centimetres  in 
length,  and  had  sharp  margins.  The  af- 
fected part  of  the  gut  was  enlarged  to 
the  size  of  the  transverse  colon,  its  lumen 
also  being  increased  in  size.  The  mes- 
enteric glands  were  enlarged.  At  the 
operation  no  other  secondary  growths 
were  seen.  The  growth  was  a  small 
round-celled  sarcoma,  starting  on  the 
submucosa,  and  had  infiltrated  all  the 
coats  of  the  bowel.  Mermet  (Bull,  de  la 
Soc.  Anat.  de  Paris,  Nov.,  '9G). 

Case  of  myosarcoma  of  the  small  in- 
testine in  a  man,  30  years  of  age,  pre- 
senting the  following  symptoms:  Pain 
in  the  left  flank,  constipation  followed 
by  diarrhoea,  emaciation,  and  a  smooth- 
surfaced  ovoid  tumor  in  the  left  side  of 
the  abdomen,  movable  and  tender. 
Operation  showed  a  tumor  of  the  small 
intestine,  which  was  removed  by  resec- 
tion of  the  bowel.  The  patient  was  in 
good  health  one  year  after  operation. 
Babes  and  Nanu  (Berliner  klin.  Woch., 
No.  7,  '97). 

The  new  growth  increases  in  size 
rapidly,  and  it  may  undergo  softening  at 
the  centre. 

The  course  of  the  disease  is  rather 
rapid,  most  cases  terminating  fatally  in 
the  course  of  nine  months. 

Of  benign  growths  of  the  bowel  ade- 
nomata are  the  most  common.  They 
may  be  flat  or  polypoid.  They  are 
variable  in  size,  although  usually  small, 
soft,  and  bleeding  readily.  Sometimes 
they  are  firm.  Their  favorite  seat  is  the 
rectum.  They  may,  however,  be  numer- 
ous and  widely  distributed.  Of  other 
non-malignant  growths  found  in  the 
large  bowel  may  be  mentioned  fibromata, 
lipomata,  papillomata,  myxomata,  angio- 
mata,  and  myomata. 


160 


INTUBATION  OF  THE  LARYNX. 


Remarkable  case  of  tumor  of  the 
vermiform  appendix,  developed  in  a  left 
inguinal  hernial  sac  containing  caecum. 
This  tumor  was  of  a  fatty  nature,  ac- 
cording to  histological  examination.  In 
the  centre  was  found  the  appendicular 
canal,  still  permeable;  it  was,  probably, 
a  submucous  lipoma.  Josserand  (Lyon 
Med.,  Jan.  3,  '92). 

Case  of  large  fibrolipoma  of  the  de- 
scending mesocolon  observed.  Twelve 
centimetres  of  the  large  intestine  were 
resected  in  removal  of  the  growth. 
Death  followed  from  shock.  Duret 
(Jour,  des  Sci.  Med.  de  Lille,  Apr.  8,  '92). 

Case  of  lipoma  in  the  descending  colon, 
which  had  been  felt  on  examination, 
was  finally  passed  at  stool.  It  was  about 
the  size  of  one's  fist,  and  was  attached 
to  the  gut  by  a  pedicle;  the  pedicle  was 
ligated  and  the  tumor  removed  by  a 
thermocautery,  the  patient  making  a 
perfect  recovery.  Link  (Wiener  med. 
Woch.,  Mar.  27,  '90). 

In  a  man  who  died  at  the  age  of  55 
years  was  found  a  double  row  of  black- 
ish prominences  on  the  large  intestine, 
containing  fsecal  matter,  solid,  but  not 
very  hard.  They  were  so  many  diver- 
ticula of  the  intestinal  cavity,  some  in 
the  mesocolon  or  the  mesorectum,  others 
in  the  pedicle  of  the  epiploic  fimbriae. 
The  first  degree  of  these  small  hernia? 
of  the  mucous  membrane  was  visibly 
constituted  by  the  normal  prominences 
of  the  intestine,  the  largest  attaining 
the  size  of  an  ordinary  marble.  These 
diverticula  began  at  the  colon  and  from 
there  extended,  augmenting  in  number 
and  volume,  to  the  rectum.  Pilliet  (Bull, 
de  la  Soc.  Anat.,  No.  G,  '94). 

These  growths  often  give  rise  to  no 
symptoms.  Sometimes  the  symptoms 
are  indefinite  and  equivocal.  Among  the 
most  common  manifestations  are  haemor- 
rhage, ana?mia,  diarrhoea,  with  mucous 
and  blood  in  the  stools  and  indications 
of  intestinal  obstruction. 

Treatment. — The  treatment  of  new 
growths  of  the  intestine  is  exclusively 
surgical.  Benign  neoplasms  may  de- 
mand no  interference,  even  though  they 


may  be  multiple.  Symptoms  of  obstruc- 
tion of  the  bowel  would  indicate  oper- 
ative intervention.  Malignant  growths 
should  be  removed,  if  possible,  as  soon  as 
recognized,  providing  all  of  the  disease 
[  can  be  excised  without  compromising 
life  and  if  metastasis  to  other  organs  have 
not  taken  place.  With  the  enterectomy 
may  be  conjoined  some  form  of  intes- 
tinal anastomosis,  or  it  may  be  necessary 
to  establish  an  artificial  anus.  The  same 
procedures  may  be  required  also  for  the 
amelioration  of  symptoms  and,  perhaps, 
the  prolongation  of  life  if  a  radical  oper- 
ation is  no  longer  practicable. 

Augustus  A.  Eshxee, 

Philadelphia. 

INTUBATION  OF  THE  LARYNX. — 

Few  operations  in  the  history  of  medi- 
cine have  excited  more  wide-spread  in- 

I  terest  than  intubation  of  the  larynx.  It 
has  fulfilled  the  expectations  of  its  advo- 
cates, and  has  fairly  and  surely  won  its 
way  in  favor,  until  it  now  outranks  the 
older  and  time-honored   operation  of 

j  tracheotomy.  We  are  indebted  to  Dr. 
Bouchut,  or  Paris,  for  the  idea  of  reliev- 
ing stenosis  of  the  larynx  by  a  tube  intro- 
duced by  way  of  the  mouth,  but  to  the 
late  Dr.  Joseph  O'Dwyer,  of  Xew  York 
City,  belongs  the  imperishable  honor  of 
reviving  the  operation  from  buried  for- 

i  getfulness,  and  by  his  ingenuity  of  so 

j  modifying  the  instruments  as  to  make 

'  them  of  practical  utility. 

The  relief  of  laryngeal  stenosis  by 
means  of  catheters  introduced  into  the 
trachea  through  the  larynx,  the  use  of 
the  short  round  tube  as  used  by  Bouchut 
(Fig.  1),  and  Dr.  O'Dwver's  early  experi- 
ments and  the  gradual  development  of 
the  instruments  (Figs.  2.  3.  4.  5,  6.  and 
7),  are  all  a  matter  of  history  which  has 
been  fully  recorded  in  medical  literature. 

I      Intubation  of  the  larynx  is  a  difficult 


INTUBATION  OF  THE  LARYNX.  INDICATIONS. 


161 


operation;  indeed,  by  many  it  is  regarded 
as  one  of  the  most  difficult  in  surgery. 
It  certainly  requires  the  maximum 
amount  of  manual  dexterity  if  it  is  to  be 
performed  with  gentleness  and  celerity. 
One  cannot  become  expert  without  con- 
siderable practical  experience. 

Theoretical  knowledge  is  important, 
but  I  would  emphasize  the  necessity  of  a 
thorough  and  careful  training  by  prac- 
tice upon  the  cadaver.   Unless  the  oper- 


bedded  in  the  larynx  as  to  produce  diffi- 
cult respiration  the  performance  of  in- 
tubation would  obviously  be  a  fatal  mis- 
take. In  cases  of  pharyngeal  abscess 
located  low  down,  causing  more  or  less 
difficulty  in  breathing,  or  the  presence  of 
retro-cesophageal  abscess,  had  better,  for 
obvious  reasons,  be  treated  otherwise. 
In  many  cases  there  is  marked  dyspnoea 
'from  great  enlargement  of  the  tonsils 
and  uvula,  associated  with  nasal  obstruc- 


Fig.  1. 


Fig.  3. 


Fig.  4. 


t 


i 


Fig.  5. 


Fig.  6.  Fig.  7. 

Gradual  development  of  intubation  instruments. 


ation  is  quickly  and  skillfully  done,  it  be- 
comes one  of  the  most  repulsive  and 
brutal  in  surgery.  This  difficult  tech- 
nique has  doubtless  had  much  to  do  with 
the  opposition  it  has  met  in  the  past. 

Indications. — In  considering  the  sub- 
ject of  intubation,  one  of  the  first  ques- 
tions raised  will  be  as  to  the  diseases  or 
conditions  calling  for  the  operation.  Are 
all  cases  of  alarming  dyspnoea  to  be 
treated  by  intubation?  Most  decidedly 
not.    In  case  of  foreign  bodies  so  im- 

4—1 


tion,  with  little  or  no  involvement  of  the 
larynx.  Intubation  would  be  useless  and 
uncalled  for  in  these  cases.  (Edema  of 
the  larynx  may  give  rise  to  great  and 
even  fatal  dyspnoea.  The  majority  of 
such  cases,  I  am  convinced,  are  better 
treated  by  tracheotomy.  In  most  of 
these  cases  the  swelling  of  the  arytenoid 
cartilages  and  of  the  epiglottis  is  so  great 
that  the  head  of  the  tube  in  the  larynx 
is  overlapped;  hence  little  relief  is  ex- 
perienced.    The  larynx  here  requires 


162 


INTUBATION  OF  THE  L. 


iARYNX.  INDICATIONS. 


rest,  which  it  cannot  obtain  with  a  large 

heavy  tube  in  situ. 

[No  form  of  acute  stenosis  of  the 
larynx,  when  situated  in  or  above  the 
chink  of  the  glottis,  ever  offers  any  very 
serious  impediment  to  passage  of  a  tube 
of  the  proper  size.  The  infiltration  of 
the  mucous  membrane,  which  is  the 
principal  cause  of  the  obstruction  in 
croup,  is  rarely,  if  ever,  confined  to  these 
parts,  but  extends  to  the  subglottic 
division  of  the  larynx.;  and,  this  being 
small  in  the  normal  condition,  any  con- 
siderable swelling  of  the  tissues  reduces 
the  breathing  space,  in  some  cases,  to  a 


Fig.  8. — Pin-head  respiratory  passage  due  to 
swelling,  as  an  obstruction  to  the  introduction 
of  a  tube. 

mere  pin-hole.  Joseph  O'Dwyer,  Assoc. 
Ed.,  Annual,  '92.] 

Two  cases  noted  in  which  it  was  im- 
possible to  introduce  the  laryngeal  tube, 
owing  to  smallness  of  the  glottis,  due  to 
oedema.  Ganghofner  (Jahrb.  f.  Kinderh. 
u.  phys.  Erzie.,  Nov.  30,  '89). 

Intubation  with  permanent  relief  of 
dyspnoea  in  case  of  subglottic  oedema, 
using  a  No.  6  tube.  Chiari  (La.  Med. 
Mod.,  Nov.  14,  '94). 

[No.  6  tube,  the  largest  of  children's 
tubes,  not  safe  in  adults,  even  immedi- 
ately after  the  age  of  puberty,  without 
a  strong  string  attached.  J.  O'Dwyer, 
Assoc.  Ed.,  Annual,  '96.] 

Literature  of  W-W-'dS. 

Intubation  is  of  great  service  in  the 
slighter  forms  of  laryngeal  obstruction 


due  to  catarrhal  inflammations,  but  in 
the  severer  forms  of  laryngeal  obstruc- 
tion intubation  is  only  slightly  more 
favorable  in  its  result  than  tracheotomy. 
A.  Jeffreys  Wood  (Intercolonial  Med. 
Jour.,  Nov.,  '97). 

Intubation  is  indicated  in  every  in- 
stance in  which  dyspnoea  is  caused  by 
laryngeal  obstruction,  except  when  due 
to  lodgment  of  a  foreign  body  in  such  a 
manner  that  the  introduction  of  a  tube  is 
mechanically  impossible.  Bernard  Wolff 
(Laryngoscope,  Nov.,  '98). 

When  we  are  called  to  a  case  of  suffo- 
cation, before  hastily  resorting  to  intuba- 
tion we  should  make  a  correct  diagnosis 
and  exclude  the  cases  in  which  this  oper- 
ation is  clearly  indicated.  This  matter 
of  differential  diagnosis  is  most  impor- 
tant, and  a  patient's  life  may  depend 
quite  as  much  upon  the  diagnostic  skill 
of  the  physician  as  upon  his  ability  to 
do  the  operation  when  indicated.  The 
special  field  and  usefulness  of  intubation 
is  in  cases  of  diphtheritic  or  membranous 
obstruction  of  the  larynx;  the  presence 
of  growths  in  children,  as  papilloma;  and 
cicatricial  stenosis  in  the  adult. 

[In  cicatricial  stricture  of  the  larynx, 
after  thorough  dilatation  has  been  ac- 
complished, intermittent  intubation,  ex- 
tending over  a  considerable  period  of 
time,  will  be  required  in  order  to  effect 
a  cure.  First  personal  case  was  of  this 
nature,  and  required  occasional  dilata- 
tion for  three  years  to  accomplish  a 
permanent  cure.  The  intervals  between 
the  intubation  were  at  first  one  week, 
which  Mas  finally  extended  to  two 
months,  the  tube  being  left  in  position 
from  one  to  three  days  on  each  occasion. 

The  significance  attached  to  the  results 
obtained  in  a  small  number  of  cases  of 
chronic  stenosis  of  the  larynx  treated  by 
intubation  is  very  different  from  that 
to  be  derived  from  an  equal  number  of 
cases  of  croup,  because  in  the  former 
tliere  are  none  of  the  complications  that 
exist  in  the  latter.  It  matters  not  how 
badly  the  patients  swallow,  no  pulmo- 
nary complications  ever  occur,  or,  at 


INTUBATION  IN  DIPHTHERIA. 


163 


least,  ever  have  occurred  in  my  experi- 
ence. Joseph  O'Dwyer,  Assoc.  Ed., 
Annual,  '92.] 

Intubation  recommended  in  certain 
cases  of  laryngeal  stenosis  from  chronic 
inflammation  or  from  accidental  or  sur- 
gical conditions.  Thomas  Annandale 
(Brit.  Med.  Jour.,  Mar.  2,  '89). 

Intubation  in  syphilitic  stenosis  af- 
fords, in  a  large  proportion  of  cases,  the 
simplest  and  most  practical  means  de- 
vised of  quickly  and  efficiently  relieving 
the  dyspnoea  of  acute  laryngeal  stenosis, 
and  for  dilating  chronic  cicatricial  strict- 
ure with  speed  and  certainty.  Lefferts 
(Med.  Rec,  Oct.  4,  '90). 

Intubation  in  infant  in  whom  nut-shell 
had  entered  larynx.  Complete  relief. 
Bonain  (Revue  Mens,  des  Mai.  de  l'En- 
fance,  July,  '95). 

Case  of  laryngeal  stenosis  in  which 
tracheotomy  was  first  performed;  strict- 
ure then  dilated  with  sounds  from  below 
until  small  tube  could  be  introduced 
from  above.  Tracheal  wound  allowed 
to  close  and  large  tubes  introduced  into 
larynx.  Cholmeley  (Birmingham  Med. 
Rev.,  May,  '95). 

[This  procedure  recommended  in 
former  editions  of  Annual.  Very  slight 
enlargement  of  tracheal  wound  only 
necessary.  From  above,  the  tube  may 
enter  one  of  the  ventricles  and  create 
false  passage.  Joseph  O'Dwyer,  Assoc. 
Ed.,  Annual,  96.] 

All  cases  of  chronic  stenosis  requiring 
intubation  are  divided  into  two  classes: 
(1)  those  in  which  the  operation  is  prac- 
ticed for  the  double  purpose  of  relieving 
existing  dyspnoea  and  at  the  same  time 
producing  gradual  dilatation  of  the 
stricture;  (2)  those  in  which  it  is  re- 
sorted to  in  order  to  get  rid  of  retained 
tracheal  cannulse.  O'Dwyer  (Jour,  of 
Laryng.,  Oct.,  '94). 

It  is  unnecessary  in  this  connection  to 
review  the  literature  of  intubation  in 
cases  of  papilloma  in  children  or  of  cica- 
tricial stenosis  in  the  adult.  It  is  a  legiti- 
mate and  often  successful  procedure  in 
both  conditions. 

Intubation  in  Diphtheria. —  In  the 
great  majority  of  cases  the  operation  will 


be  called  for  to  relieve  the  impending 
suffocation  in  diphtheritic  or  so-called 
membranous  croup. 

In  cases  of  diphtheritic  or  mem- 
branous stenosis  of  the  larynx,  which 
conditions  I  believe  to  be  identical  with 
perhaps  a  very  few  exceptions,  it  often 
becomes  a  nice  question  of  judgment  as 
to  when  we  should  interfere  surgically. 
Shall  we  operate  early  with  the  first 
symptoms  of  laryngeal  invasion  or  wait 
until  it  is  evident  the  patient  must  die 
unless  given  relief?  I  would  say  that  if 
we  operate  early  we  will  do  so  in  many, 
in  these  days  of  antitoxin,  that  would  re- 
cover without  operation;  on  the  other 
hand,  if  we  operate  late,  after  the  patient 
has  become  comatose,  and  unconscious, 
we  will  lose  cases  that  would  recover 
otherwise.  It  does  not  often  happen  that 
the  operation  is  done  early,  as  it  is  gen- 
erally performed  by  the  specialist,  who 
is  only  called  in  as  a  last  resort.  I  believe 
it  can  be  safely  said  that  the  operation  is 
more  frequently  performed  too  late  to 
give  the  best  chances  of  recovery  than 
too  early.  Inasmuch  as,  properly  carried 
out,  the  operation  in  no  wise  com- 
promises the  case  or  adds  to  its  danger, 
but  gives  comfort,  relieves  suffering,  and 
prevents  exhaustion,  there  seems  to  be 
no  valid  reason  why  the  operation  should 
be  postponed  after  certain  well-marked 
symptoms  have  occurred. 

There  are  signals  of  danger  and  dis- 
tress which  should  never  be  passed  un- 
heeded and  which,  once  recognized,  ren- 
der the  operation  imperative.  When  the 
voice  becomes  toneless,  and  whispering 
and  the  cough  suppressed;  when,  in  ad- 
dition, the  dyspnoea  becomes  urgent,  and 
the  loud  stridor  of  croup  is  heard  both 
during  inspiration  and  expiration;  when 
there  is  marked  recession  at  the  base  of 
the  sternum  and  above  the  clavicles;  and 
when  all  these  symptoms  cannot  be  re- 


164: 


INTUBATION  IN  DIPHTHERIA.  TECHNIQUE. 


lieved  by  emetics,  it  is  certainly  time  to 
operate. 

While  we  are  not  justified  in  waiting 
longer  after  these  symptoms  have  ap- 
peared, it  is  even  better  when  possible  to 
operate  earlier.  When  the  diagnosis  of 
■diphtheritic  or  membranous  laryngitis  is 
clear  and  positive,  as  indicated  by  the 


Fig.  9. — Course  of  the  tube  from  the  mouth  to 
the  laryngeal  cavity. 


voice  and  cough,  beginning  dyspnoea,  the 
bacteriological  examination,  and  the 
gradually  increasing  distress,  in  spite  of 
treatment,  I  believe  we  should  not  wait 
until  the  condition  becomes  alarming. 
Again,  in  infants,  and  in  young  and 
feeble  subjects,  the  dyspnoea,  while  not 


sufficient  to  give  rise  to  marked  cyanosis 
or  alarming  symptoms  of  suffocation, 
may,  nevertheless,  be  sufficient  to  cause 
dangerous  or  even  fatal  exhaustion.  In 
these  cases  it  is  our  plain  duty  to  operate 
earlier  than  when  the  patients  are  older, 
more  rugged,  and  better  able  to  stand  the 
exhaustion  caused  by  difficult  respiration. 

In  all  cases  of  intended  intubation  the 
surgeon  should  have  instruments  ready 
at  hand  for  tracheotomy,  and  should  not 
only  have  the  consent  of  the  parents  for 
intubation,  but  for  tracheotomy,  also, 
if  the  latter  should  become  necessary. 
Bays  (Lancet,  Sept.  20,  '90). 

Literature  of  '96-'97-'98. 

Intubation  should  be  practiced  in  all 
cases  presenting  any  one  of  the  follow- 
ing symptoms  prominently:  Deep  epi- 
gastric recession  with  each  inspiration, 
labored  and  prolonged  expiration,  ex- 
treme restlessness,  spasmodic  attacks 
coming  on  at  intervals,  or  persistent 
cyanosis.  In  cases  seen  late  it  might  be 
wiser  to  intubate  and  administer  anti- 
toxin rather  than  administer  antitoxin 
and  wait  for  its  effects  before  intuba- 
tion. H.  M.  McClanahan  (Brit.  Med. 
Jour.,  July  9,  '98). 

The  indications  of  successful  introduc- 
tion of  the  tube  are  relief  of  dyspnoea, 
and  violent,  straining  cough.  It  is  im- 
portant that  this  cough  should  be  pres- 
ent, as  it  causes  expulsion  of  loose  mem- 
brane. If  it  be  absent  a  drink  of  whisky 
should  be  given  to  excite  it.  Bernard 
Wolff  (Laryngoscope,  Nov.,  ?9S). 

Technique. — Prelimina  ry  Pr act  h  i:. 

— Preliminary  practice  upon  the  ad  nit 
cadaver  is  of  but  little  help  in  acquiring 
the  operative  technique  for  children. 
The  adult  larynx,  in  the  cadaver,  is  al- 
most beyond  the  reach  of  the  finger;  the 
epiglottis  is  prominent,  while  the  cavity 
of  the  larynx  is  large  and  easily  deter- 
mined. In  young  children,  however,  the 
|  epiglottis  is  small:  while  the  rima  glot- 
i  tidis  feels  to  the  touch  as  a  mere  slit  or 
depression.   By  referring  to  Fig.  0  it  will 


INTUBATION  IN  DIPHTHERIA.  TECHNIQUE. 


165 


be  seen  that  if  the  epiglottis  is  drawn  for- 
ward with  the  finger  and  the  tube  is 
passed  in  the  median  line  with  its  point 
hugging  the  anterior  wall,  it  must  neces- 
sarily pass  into  the  larynx.  It  is  impor- 
tant to  follow  preceisely  the  median  line 
and  to  hug  the  anterior  wall  with  the 
point  of  the  tube. 

Many  operators  prefer  to  perform  the 
operation  in  the  adult  by  the  aid  of  the 
laryngeal  mirror.  The  patient  holds  the 
tongue  (with  a  napkin  or  soft  towel  be- 
tween the  thumb  and  forefinger  of  the 
right  hand)  well  drawn  out,  while  the 
operator,  sitting  in  front  and  aided  by 
reflected  light  from  a  mirror  on  the  fore- 
head and  by  the  laryngeal  mirror,  guides 
the  tube  over  the  epiglottis  and  engages 
its  point  in  the  cavity  of  the  larynx. 
Quickly  dropping  the  laryngeal  mirror 
from  the  left  hand  he  then  passes  the 
forefinger  down  upon  the  head  of  the 
tube  and  crowds  it  into  position.  One 
accustomed  to  laryngeal  work  will  per- 
form the  operation  in  this  manner  very 
readily,  but  the  procedure  is  practically 
impossible  for  one  not  familiar  with 
laryngeal  instruments  and  their  use. 

[In  chronic  cases,  in  which  the  throat 
has  become  more  or  less  accustomed  to 
the  use  of  instruments,  intubation  can  be 
performed  with  greater  facility  and  with 
less  discomfort  to  the  patient  by  the  aid 
of  the  mirror  than  by  the  usual  method. 
Joseph  O'Dwyer,  Assoc.  Ed.,  Annual, 
'92.] 

Intubation  in  children  by  this  method 
is  impracticable.  The  patient  must  be 
properly  held  before  a  good  light.  The 
base  of  the  tongue  is  held  down  with  a 
tongue-depressor,  and,  as  the  epiglottis 
rises  to  view,  the  point  of  the  tube  is 
directed  into  the  larynx,  passing  immedi- 
ately behind  the  epiglottis.  The  tube  is 
then  pressed  down  into  position  with  the 
forefinger  of  the  left  hand  as  the  tube  is 
released  from  its  introducer.   As  soon  as 


the  point  of  the  tube  passes  over  the  epi- 
glottis, the  hand  holding  the  introducer 
must  be  quickly  elevated,  keeping  the 
point  of  the  tube  stationary  until  the 
turn  is  made,  in  order  that  the  tube  may 
pass  down  at  an  acute  angle.  Otherwise 
the  tube  will  invariably  slide  over  into 
the  oesophagus.    The  annexed  cut  shows 


Fig.  10. 


how  such  a  misdirection  can  be  given 
the  tube.  This  method,  however,  is  not 
to  be  preferred;  but  it  may  be  employed 
by  those  who  do  not  possess  or  who  can- 
not acquire  the  manual  dexterity  to  per- 
form the  operation  with  the  assistance  of 
the  tactile  sense  alone,  i.e.,  unaided  by 
the  eye. 

The  ideal  operation  should  be  con- 


166 


INTUBATION  IN  DIPHTHERIA.  TECHNIQUE. 


ducted  through  the  sense  of  touch  en- 
tirely. One  should  handle  the  instru- 
ments frequently;  the  sliding  spring  of 
the  introducer,  shown  in  the  cut,  should 
be  moved  by  the  thumb  and  not  by  the 
forefinger.   The  extractor  should  be  held 


important  also  to  practice  extracting  it 
from  the  closed  hand  of  another.  Intro- 
ducing and  extracting  the  tube  from  the 
larynx  of  a  small  dog  under  an  anaesthetic 
will  frequently  be  of  great  help  in  acquir- 


ing dexterity. 


Fig.  11. 


in  the  manner  indicated  by  the  second 
figure.  By  frequently  introducing  the 
tube  into  the  closed  hand  of  another  per- 
son, holding  the  introducer  in  the  right 
hand,  detaching  the  tube  and  pressing  it 
down  with  the  forefinger  of  the  left  hand 
in  the  exact  manner  as  when  introduced 
into  the  larynx,  slight  practical  experi- 


The  instruments  should  be  held 
lightly.  Little  or  no  force  should  be 
used,  no  anaesthetic  is  necessary,  and  the 
operation  should  not  require  longer  than 
from  five  to  ten  seconds.  It  occasionally 
happens  that  when  the  end  of  the  tube 
reaches  the  larynx,  and  before  it  becomes 
engaged,  spasm  of  the  larynx  occurs.  In 


Fisr.  12. 


ence  can  be  gained.  One  should  become 
so  familiar  with  the  instruments  that  the 
various  steps  of  the  operation  can  be  car- 
ried out,  so  to  say,  automatically. 

As  the  extraction  of  the  tube  is  even 
more  difficult  than  its  introduction,  it  is 


such  a  case  it  is  best,  instead  of  using 
force,  to  simply  wait  a  few  seconds,  hold- 
ing the  tube  in  position.  The  patient 
will  then  endeavor  to  breathe,  the  spasm 
will  relax,  and  the  tube  will  drop  into 
position. 


INTUBATION  IN  DIPHTHERIA.  TECHNIQUE. 


167 


In  performing  the  operation  the  phy- 
sician  should  first  select  a  tube  appropri- 
ate for  the  age  of  the  patient,  as  indi- 
cated by  a  scale  that  accompanies  every 
set  of  instruments.  The  tube  should 
then  be  threaded  with  silk  or  linen 
thread,  making  a  loop  about  fourteen 
inches  in  length.  The  obturator  fitting 
the  tube  to  be  Used  (Fig.  7)  should  then 
be  screwed  upon  the  introducer  if  the 
O'Dwyer  instruments  are  used,  and  the 
tube  attached.  It  is  now  ready  for  use, 
and  should  be  placed  upon  the  table 
within  easy  reach.  The  patient  should 
be  held  upright  in  the  lap  of  the  nurse 
supported  closely  against  the  left  chest 
with  the  head  resting  on  the  shoulder. 
The  nurse  should  sit  upright  in  a  j 
straight-backed  chair  and  the  patient  be 
held  firmly  and  not  be  allowed  to  slide 
down.  The  forearms  of  the  child  should 
be  crossed  in  front  and  the  nurse  should 
grasp  the  wrists,  the  left  wrist  with  the 
right  hand  and  the  right  wrist  with  her 
left  hand.  The  gag  is  then  introduced 
in  the  left  angle  of  the  mouth  well 
back  between  the  teeth  and  widely 
opened  (Fig.  13).  The  operator  standing 
in  front  then  quickly  seizes  the  intro-  I 
ducer  with  tube  attached,  hooks  the  loop  I 
or  bridle  over  the  little  finger  of  the  left 
hand,  and  introduces  the  index  finger  of  j 
the  same  hand  closely  followed  by  the 
tube  (Fig.  14).  He  raises  the  epiglottis 
forward  with  the  index  finger  (Fig.  9) 
and  guides  the  end  of  the  tube  gently 
over  it  when,  by  making  an  abrupt  turn, 
he  will  pass  the  tube  into  the  larynx  if 
he  has  been  careful  to  keep  in  the  median 
line;  or  he  may  pass  the  index  finger 
over  the  epiglottis  and  upon  the  aryte-  j 
noid  cartilages  and  guide  the  end  of  the 
tube  into  the  larynx. 

My  method  is  to  feel  for  the  small 
opening  or  depression  just  back  of  the 
epiglottis  with  the  finger  and  guide  the 


end  of  the  tube  into  it.  In  any  case  the 
end  of  the  tube  should  pass  under  the  tip 
of  the  finger,  not  over  it  or  by  the  side 
of  it,  but  directly  under  it.  The  moment 
the  end  of  the  tube  engages  the  larynx 
the  right  hand,  holding  the  introducer, 


Fig.  13. 


should  be  quickly  elevated  allowing  the 
tube  to  pass  down  at  right  angle.  Simul- 
taneously the  tube  is  loosened  from  the 
introducer  by  pressing  forward  the  slide 
with  the  thumb.  The  index  finger  of  the 
left  hand,  which  has  acted  as  guide,  is 
placed  upon  the  head  of  the  tube  and 


168 


INTUBATION  IN  DIPHTHERIA.  TECHNIQUE. 


gently  presses  it  down  into  position  as 
the  introducer  is  removed.  It  is  impor- 
tant to  bear  in  mind  the  necessity  of 
hugging  the  anterior  wall  with  the  end 
of  the  tube  as  it  is  introduced.  In  order 
to  do  this,  it  should  follow  a  gentle  curve, 
until  it  has  passed  over  the  epiglottis,  and 
remain  stationary  for  an  instant  as  far  as 


I  line,  the  tube  will  invariably  pass  into 
the  oesophagus. 

A  prolonged  attempt  at  introducing 
the  tube  should  be  avoided.  Many  brief 
trials  characterized  by  gentleness  will  do 
much  less  harm.  If  during  the  first  at- 
tempt the  tube  passes  into  the  oesopha- 
gus, the  instrument  and  the  finger  should 


downward  progress  is  concerned,  while 
the  handle  is  quickly  elevated.  The  dark 
line  in  Fig.  15  represents  the  curve  that 
should  be  followed  by  the  end  of  the  tube 
while  it  is  being  introduced.  This  sud- 
den turn  constitutes  one  of  the  salient 
points  of  the  operation,  for  if  the  curve 
be  continued  as  indicated  bv  the  dotted 


be  removed  from  the  throat,  and  the  pa- 
tient be  allowed  to  recover  his  breath  for 
a  moment.  A  new  trial  is  then  made. 
Entrance  of  the  tube  into  the  larynx  is 
indicated  by  violent  coughing  and  by 
easy  respiration,  if  the  tube  is  not  blocked 
by  membrane  below  it. 

To  ascertain  whether  the  tube  is  in 


INTUBATION  IN  DIPHTHERIA. 


TECHNIQUE. 


169 


position  the  child,  sitting  upright,  is  al- 
lowed to  drink  a  small  quantity  of  water 
from  a  glass;  if  the  tube  is  in  the  larynx 
violent  coughing  will  result.  If  it  is  in 
the  oesophagus  there  will  be  no  violent 
coughing,  no  relief  from  the  threatening 
suffocation,  and  there  will  also  be  a 
gradual  shortening  of  the  loop  as  the 
tube  gravitates  toward  the  stomach. 

If  the  operator  is  quite  certain  that  the 
tube  has  entered  the  larynx  the  gag 
should  be  removed  and  the  loop  placed 
backward  over  the  ear.  While  doing  this, 
the  hands  of  the  patient  should  be  held 
firmly  by  the  nurse,  otherwise  the  child 
will  grasp  the  thread,  pull  out  the  tube, 
and  the  procedure  will  have  to  be  re- 
newed. The  operator  should  wait  a  few 
minutes  to  make  sure  that  the  tube  is  in 
position,  and  to  allow  the  cough  to  expel 
the  mucus  and  softened  membrane.  He 
should  then  replace  the  gag,  cut  the  loop 
near  the  mouth  and  introduce  the  index 
finger  of  the  left  hand  until  it  reaches 
the  head  of  the  tube.  This  is  held  down 
while  the  thread  is  removed  by  pulling 
on  one  end  of  the  loop. 

Literature  of  '96-'97-'98. 

The  string  should  be  permitted  to  re- 
main in  place,  being  passed  over  the  left 
ear,  until  quiet  breathing  is  restored, 
from  fifteen  minutes  to  half  an  hour, 
and  should  then  be  removed  by  cutting 
one  side  of  the  loop  close  to  the  mouth, 
taking  hold  of  the  long  end,  and  with- 
drawing while  the  left  forefinger  is 
making  gentle  pressure  down  on  the 
head  of  the  tube.  Never,  under  any  cir- 
cumstances, should  the  string  be  removed 
without  making  pressure  on  the  head  of 
the  tube,  as  the  string  becomes  twisted 
in  the  mouth  and  will  be  caught  in  the 
eyelet  of  the  tube  and  the  latter  itself 
withdrawn  unless  the  counter-pressure 
is  made.  Another  very  important  pre- 
caution is  that  the  person  holding  the 
child  should  never  release  the  child's 
hands  until  the  string  is  removed  by  the 


surgeon.  W.  K.  Simpson  (Med.  News, 
Mar.  19,  '98). 

If,  in  introducing  the  tube,  membrane 
is  crowded  down  ahead  of  it  and  respira- 
tion is  difficult  or  impossible,  as  a  conse- 
quence, the  patient  should  be  encour- 
aged to  cough  violently.  As  he  does  this 
the  tube  should  be  quickly  jerked  by 
means  of  the  thread  still  attached.  Fre- 
quently a  large  mass  of  membrane  will 
be  expelled.  If  this  does  not  occur  stim- 
ulants and  water  should  be  given  and 
violent  coughing  encouraged. 

It  will  occasionally  happen  that  in 
spite  of  all  efforts  a  patient  is  unable  to 
expel  the  offending  and  obstructing 
membrane.   In  such  a  case  it  is  necessary 


Fig.  15, 


to  employ  a  long  pair  of  tracheal  forceps 
and,  as  the  child  coughs,  endeavor  to 
grasp  the  membrane  and  remove  it.  If 
still  unsuccessful  our  last  resort  is  to  per- 
form tracheotomy  and  extract  the  mem- 
brane. This,  however,  is  rarely  neces- 
sary. 

Out  of  two  hundred  cases  in  only  two 
has  the  membrane  been  crowded  down 
sufficiently  to  produce  asphyxiation,  and 
in  both  of  these  it  was  immediately 
coughed  out  on  removal  of  the  tube. 
O'Dwyer  (Med.  News,  June  23,  '88). 

Pushing  down  of  the  pseudomembrane 
by  intubation  is  seldom  observed,  and 
only  in  rare  cases  ends  fatally.  The 
asphyxia  caused  by  it  can  be  relieved 
by  extubation,  and  the  loosened  mem- 
brane will  be  expectorated.    If  no  ex- 


170 


INTUBATION  IN  DIPHTHERIA.  AFTER-TREATMENT. 


pectoration  follows  extubation,  artificial 
respiration  must  be  performed,  and,  if 
this  has  no  effect  tracheotomy  should  be 
performed.  The  later  obstruction  of  the 
tube  by  pseudomembrane  rarely  occurs. 
The  thread  should  be  fixed  to  the  child's 
neck,  so  that  extubation  could  be  per- 
formed by  the  nurse  if  necessary.  Bokay 
(Pester  med.-chir.  Presse,  No.  12,  '94). 

Literature  of  '96-'97-'98-'99. 

Of  498  intubation  cases,  an  immediate 
tracheotomy  became  necessary  in  3 1/2 
per  cent,  on  account  of  detachment  of 
pseudomembrane.  Tracheotomy  failed 
to  relieve  the  asphyxia  in  only  2  of  these 
cases,  and  these  patients  died  from 
the  pushing  down  of  pseudomembrane. 
Immediate  extubation  leads,  in  most 
cases,  to  the  result  that  the  loosened 
pseudomembrane  is  ejected  by  violent 
coughing,  either  simultaneously  with  the 
tube  or  directly  after  it.  Johann  v. 
Bokay,  translated  by  Edward  M.  Plum- 
mer  (Annals  of  Gyn.  and  Pediatry,  Jan., 
'99). 

After  the  tube  has  been  successfully 
introduced  the  patient  experiences  entire 
relief.  The  change  in  the  appearance  of 
the  patient  is  not  only  immediate,  but 
remarkable. 

The  loud  stridor,  sometimes  heard  all 
over  the  house,  the  projecting  eyeballs, 
the  livid  features,  the  cyanosis,  the 
clutching  at  the  throat,  the  piteous 
begging  in  a  whispering  voice  for  help, 
cease  as  if  by  magic.  The  patient  lies 
pale  and  quiet.  The  loud  stridor  is  re- 
placed by  almost  noiseless  respiration, 
and  death  is  held  at  bay.  The  patient 
falls  into  quiet  refreshing  slumber. 

After-treatment  of  Intubated  Cases. — 
Rest  and  nutrition  are  now  important. 
In  former  days  the  question  of  feeding 
was  beset  with  many  difficulties,  but  now 
happily  these  obstacles  have  been  largely 
overcome.  It  was  found  by  Drs.  Frank 
Carey  and  William  E.  Casselberry,  of 
Chicago,  while  jointly  treating  a  case, 
that  if  the  patient  were  placed  in  the 


recumbent  position,  with  the  head 
slightly  lower  than  the  shoulders,  swal- 
lowing could  be  effected  with  little  diffi- 
culty. This  discovery  marked  a  great 
advance  in  the  successful  management  of 
these  cases,  and  has  added  not  a  little  to 
the  success  of  the  operation  and  to  the 
comfort  of  the  little  sufferers. 

In  order  to  obviate  the  difficulties  of 
administering  liquids  to  patients  who 
have  undergone  intubation,  the  child 
should  be  placed  head  downward  on  an 
inclined  plane;  an  angle  of  from  45  to 
90  degrees  seems  necessary  to  obtain  the 
best  results.  The  child  is  held  on  its 
back  in  the  arms  of  the  nurse,  the  feet 
elevated,  and  the  head  left  to  hang  over 
the  arm,  then  it  may  take  the  mouth  of 
the  feeding-bottle,  suck  through  a  tube 
from  a  glass,  or  feed  from  a  spoon.  The 
only  difficulty  is  encountered  when  the 
child  is  again  placed  in  the  upright  posi- 
tion, which  posture  it  must  not  be  per- 
mitted to  regain  until  it  has  been  made 
to  swallow  three  or  four  times  after  the 
vessel  of  liquid  has  been  taken  from  its 
mouth,  in  order  to  swallow  all  the  fluid 
which  has  gravitated  into  the  pharynx 
and  naso-pharynx.  Casselberry  (Chicago 
Med.  Jour,  and  Examiner,  Oct.,  '88). 

The  mechanism  is  simple  enough:  the 
tube  being  on  an  incline,  the  fluid  cannot 
drop  into  it.  The  patient  should  be 
placed  on  a  pillow  with  the  head  extend- 
ing slightly  over  it,  either  on  the  back  or 
the  side,  preferably  the  side;  the  pillow 
is  moved  over  the  side  of  the  bed  and 
the  head  is  slightly  depressed.  If  the 
head  is  lowered  too  much  the  fluid  will 
pass  into  the  post-nasal  space  and  nasal 
cavities,  while  if  it  is  raised  too  much 
it  will  pass  through  the  tube  and  into 
the  lungs  and  cause  violent  coughing. 
A  few  trials  will  demonstrate  the  re- 
quired position  in  each  individual  case. 
With  a  little  patience  and  firmness  a 
child  should  take  abundance  of  liquid 
nourishment  without  difficulty.  The 
physician  should  himself  attend  person- 


INTUBATION  IN  DIPHTHERIA.  AFTER-TREATMENT. 


171 


ally  to  this  matter  until  the  attendants 
are  so  trained  that  they  are  fully  capable. 

Literature  of  '96-'97-'98. 

In  feeding  children,  while  the  tube  is 
in  the  larynx,  the  writer  prefers  to  have 
the  patient  lie  on  the  stomach,  face 
down,  as  this  gives  greater  command 
over  the  constrictors.  Thomas  J.  Hillis 
(N.  Y.  Med.  Jour.,  Dec.  5,  '96). 

It  is  best  to  give  water  and  food  from 
a  spoon,  although  some  children  will  pre- 
fer to  draw  it  through  a  glass  or  rubber 
tube.  The  nourishment  should  be  milk, 
beef-juice,  or  the  various  soups,  although 
semisolids — as  custards,  ice-cream,  and 
the  like — may  be  allowed  in  case  there  is 
repugnance  for  the  more  fluid  foods. 
Milk  is  the  most  convenient,  and  usually 
the  best  food  that  can  be  given  in  these 
cases. 

Eegarding  the  after-treatment,  little 
need  be  said.  Antitoxin  should  have 
been  given  at  the  very  onset  of  the  dis- 
ease and  should  have  been  repeated.  If 
not,  it  should  now  be  given  in  large 
dosage  and  again  repeated  in  twelve  or 
sixteen  hours.  If  there  is  a  tendency  of 
the  membrane  to  extend  downward,  indi- 
cated by  quickened  respiration  and  some- 
times by  rales  or  roughened  or  harsh 
respiratory  sounds,  then  the  antitoxin 
should  be  crowded  to  the  limit. 

Literature  of  '96-'97-'98. 

Report  of  twenty-nine  cases  of  intuba- 
tion with  the  combined  use  of  antitoxin. 
All  the  cases  were  seen  in  consultation, 
and  in  all  of  them  the  operation  was 
urgently  required.  Three  were  under 
two  years  of  age,  with  two  recoveries, 
or  66  2/3  per  cent. ;  eight  were  two  years 
old,  with  eight  recoveries,  or  100  per 
cent.  ;  six  were  three  years  old,  with  six 
recoveries,  or  100  per  cent.;  six  were 
four  years  old,  with  five  recoveries,  or 
83  V..  per  cent. ;  two  were  five  years  old, 
with  two  recoveries,  or  100  per  cent.;  and 
four  were  six  years  old,  with  four  re- 
coveries, or  100  per  cent.   Total,  twenty- 


nine  cases  with  twenty-seven  recoveries, 
or  93.1  per  cent.,  a  mortality  of  only  6.9 
per  cent.  This  great  reduction  in  the 
mortality  is  attributed  to  the  full  and 
free  use  of  antitoxin  in  all  the  cases. 
Waxham  (Archives  of  Pediatrics,  Mar., 
'9S). 

If  the  case  is  not  one  of  mixed  infec- 
tion all  sprays  and  douches  and  applica- 
tions to  the  throat  can  be  abandoned. 
In  case  of  mixed  infection  if  there  is 
much  offensive  discharge  from  the  nose 
and  throat  a  simple  non-irritating  anti- 
septic solution  should  be  gently  used  in 
the  nasal  cavities  with  the  douche  or 
syringe  and  in  the  throat  by  means  of  the 
spray;  at  the  same  time  giving  antitoxin 
and  supporting  the  patient  by  stimulants 
and  nourishment.  How  long  should  the 
tube  be  allowed  to  remain  in  the  larynx? 
This  will  depend  upon  circumstances  en- 
tirely. If  there  is  a  considerable  amount 
of  membrane  in  the  trachea  it  must 
necessarily  come  away;  sometimes  it 
softens  down  and  is  expelled  through  the 
tube  in  the  form  of  muco-pus  without 
difficulty,  but  not  infrequently  large 
flakes  or  patches  become  loosened  and 
endanger  the  life  of  the  patient  by  ob- 
structing the  tube.  If  a  too  tightly 
fitting  tube  has  not  been  used  it  will  fre- 
quently be  expelled  on  the  second  or 
third  day  on  account  of  obstructing  mem- 
brane below  it  and  commonly  it  will  not 
be  necessary  to  replace  it.  It  is  always  to 
be  feared,  however,  that  the  tube  may  not 
be  expelled  when  it  becomes  obstructed. 
Whenever  there  is  evidence  of  partially 
detached  membrane  below  the  tube,  indi- 
cated by  a  flapping  sound,  a  peculiar 
hoarseness  of  the  cough,  or  by  sudden 
and  evident  closure  of  tube  during  an  ex- 
pulsive cough  we  should  at  once  extract 
the  tube  whether  it  has  been  in  one  day 
or  three  days  or  four  days,  or  else  remain 
constantly  with  the  patient  in  order  to 
extract  the  tube  in  case  total  obstruction 


72 


INTUBATION  IN  DIPHTHERIA.    OBSTRUCTION  OF  TUBE. 


occurs  and  the  patient  is  unable  to  ex- 
pel it. 

Literature  of  '96-'97-'98. 

In  cases  where  antitoxin  has  been  used 
it  is  advisable  to  extubate  after  thirty- 
six  or  forty-eight  hours.  This  is  the 
time  when,  by  the  action  of  the  anti- 
toxin, the  membrane  is  being  thrown  off. 


Fig.  16. 


It  may  be  necessary  to  reintubate.  J.  C. 
Connell  (Brit.  Med.  Jour.,  June  5,  '97). 

The  principal  indications  for  removing 
the  tube  previous  to  its  final  removal  arc 
severe  discomfort  or  pain  from  pressure, 
especially  if  the  pain  be  radiating  in 
character,  severe  attacks  of  coughing, 
and  sudden  stenosis  due  to  the  lodgment 
of  membrane  in  the  lumen  of  the  lube. 


W.  K.  Simpson  (Med.  News,  Mar.  19, 
'98). 

Obstruction  of  Tube. — The  attendants 
should  be  instructed  in  case  of  emer- 
gency if  obstruction  occurs  suddenly  to 
hold  the  child  with  the  head  down  shak- 
ing him,  while  another  suddenly  and 
sharply  strikes  the  patient  a  smart  blow 
upon  the  chest  and  back. 

Literature  of  '96-'97-'98. 

Syncope  caused  by  intubation  of  the 
glottis  should  be  treated  by  repeated 
blows  upon  the  back  and  precordial 
region,  the  child  being  held  with  the 
head  downward.  Poulet  (Bull.  Gen.  de 
Therap.,  Nov.  8,  '96). 

In  case  total  obstruction  occurs  the 
child  will  die  in  a  few  moments  unless 
the  tube  can  be  expelled.  Happily  these 
emergencies  do  not  frequently  occur.  If 
everything  goes  smoothly  and  the  patient 
is  taking  nourishment  well  and  there  has 
occurred  no  evidences  of  obstruction  it  is 
my  custom  to  remove  the  tube  on  the 
fourth  or  fifth  day.  It  will  very  seldom 
happen  that  the  tube  will  be  necessary 
for  a  longer  time,  providing  the  opera- 
tion has  been  skillfully  performed  and 
no  damage  has  been  done  to  the  larynx. 
The  shorter  time  the  tube  is  worn  the 
less  likely  are  we  to  meet  with  paralysis 
of  the  vocal  cords  and  other  conditions 
that  often  require  its  long  continued  use. 

In  extracting  the  tube  the  patient 
should  be  placed  in  the  same  position  as 
when  it  is  introduced.  The  gag  should 
be  placed  as  before  and  the  index  finger 
of  the  left  hand  introduced  until  it 
reaches  the  head  of  the  tube.  The  ex- 
tractor, held  in  the  right  hand,  should 
quickly  follow  the  finger,  the  point  of 
which  should  be  guided  into  the  tube. 
(Fig.  1(>.)  By  pressing  on  the  lever 
above  the  handle  the  jaws  of  the  instru- 
ment are  separated,  thus  holding  the 
tube  securely  while  it  is  removed. 


INTUBATION  IN  DIPHTHERIA. 


PROLONGED  USE  OF  TUBE. 


173 


Literature  of  '96-'97-'98. 

In  a  case  where  attempts  at  extraction 
caused  a  small  tube  to  sink  farther  down 
into  the  larynx,  pressure  made  with  the 
thumb  on  the  trachea,  just  below  the 
cricoid  cartilage,  where  the  end  of  the 
tube  could  be  felt,  caused  cough,  which 
forced  the  tube  out.  This  method  of  ex- 
pression never  failed  in  subsequent  cases. 
The  pressure  may  be  made  with  both 
thumbs  inward  and  directly  upward.  If 
a  more  powerful  pressure  is  exerted  the 
tube  may  be  forced  entirely  out  of  the 
mouth.  Trumpp  (Munch,  med.  Woch., 
Apr.  28,  '96). 

While  it  is  the  rule  that  the  tube  is  no 
longer  necessary  after  the  fourth  or  fifth 
day  and  frequently  not  after  the  second 
or  third,  yet  it  sometimes  occurs  that  it 
cannot  be  dispensed  with  for  two,  three, 
or  six  weeks,  or  even  longer.  After  its 
removal  the  dyspnoea  returns,  sometimes 
immediately,  and  sometimes  after  a  few 
hours,  occasionally  after  one  or  two  days 
have  passed. 

It  is  always  well  to  remain  with  the 
patient  an  hour  after  the  removal  of  the 
tube  or  be  within  ready  call  in  order  to 
replace  the  tube  in  case  of  emergency. 
Cases  of  sudden  death  have  occurred 
from  returning  dyspnoea  after  the  opera- 
tion has  left  the  patient  in  fancied  se- 
curity. As  a  rule,  the  dyspnoea  returns 
slowly;  so  that  it  is  several  hours  before 
the  patient  is  in  an  alarming  condition. 
Occasionally  it  returns  suddenly  and  al- 
most immediately  after  the  removal  of 
the  tube. 

Prolonged  Use  of  Tube.  —  A  number 
of  causes  have  been  enumerated  as 
rendering  necessary  the  long-continued 
use  of  the  tube.  Principal  among  them 
may  be  mentioned  the  formation  of 
diphtheritic  exudate  or  its  long  persis- 
tence in  the  larynx  and  trachea;  oedema 
of  the  tissues;  ulceration  of  the  cricoid 
cartilage  and  consequent  collapse  of  the 
thyroid   cartilage;    cicatricial  contrac- 


tions and  exuberant  granulations  follow- 
ing ulcerations  and  abduction  paralysis. 

In  some  of  these  the  lesions  are  due  to 
a  too  tightly  fitting  tube,  to  leaving  the 
tube  in  too  long,  to  poorly-constructed 
instruments,  and  some  to  injuries  result- 
ing from  unskillful  operations. 

With  the  use  of  antitoxin,  which  en- 
ables the  patient  to  dispense  with  the 
tube  at  an  earlier  day,  and  greater  skill 
acquired  in  performing  the  operation, 
these  conditions  will  less  frequently  arise. 

An  important  point  to  emphasize  is 
that  when  the  operator  appreciates  the 
fact  that  a  tube  is  too  large,  as  indicated 
by  the  force  required  to  press  it  down 
into  position,  he  should  at  once  remove 
it  and  use  a  smaller  one.  The  unduly 
large  one  will  not  only  cause  ulceration 
or  paralysis  from  undue  pressure,  but,  in 
case  of  obstruction  below  the  tube,  also 
give  rise  to  exfoliation  of  membrane. 
There  will,  furthermore,  be  great  danger 
of  sudden  suffocation  from  the  inability 
of  the  patient  to  expel  the  tube. 

Erosion  of  the  mucous  membrane  and 
exposure  of  the  cartilages  observed  at 
the  autopsy  in  4  of  42  cases.  Ganghofner 
(Jahrb.  f.  Kinderh.  u.  phys.  Erzie.,  Nov. 
30,  '90). 

Case  in  which  use  of  catgut  led  to  fatal 
asphyxia  and  to  belief  that  tube  had 
fallen  into  trachea,  the  catgut  having 
absorbed  moisture  and  appearing  as  soft 
tissue  to  ringer.  Delvincourt  (Union 
Med.  du  Nord-est,  June  30,  '95). 

[This  is  sufficient  to  produce  fatal 
apnoea,  a  silk  thread  having  produced 
serious  obstruction.  In  performing  tra- 
cheotomy after  intubation,  it  is  impor- 
tant to  remember  that,  unless  the  cricoid 
cartilage  be  cut,  it  is  impossible  to  pull 
tube  downward.  It  must  be  pushed  up- 
ward with  small  forceps  or  by  lateral 
external  pressure.  Joseph  O'Dwyer, 
Assoc.  Ed.,  Annual,  '96.] 

Prolonged  intubation  and  consecutive 
ulceration  of  trachea  and  mediastinal  ab- 
scess. Meslay  (Jour,  de  Med.  de  Bor- 
deaux. July.  '95). 


1U 


INTUBATION  IN  DIPHTHERIA.    PROLONGED  USE  OF  TUBE. 


Decreasing  length  of  tube  a  means  of 
obviating  obstruction  accidents.  Bayeux 
(La  Med.  Moderne,  May  25,  '95). 

[Length  is  as  important  as  breadth, 
thickness,  or  calibre.  The  present  length 
was  adopted,  not  after  experiments  on 
cadaver,  but  on  the  living,  steps  being 
suggested  by  post-mortem  findings. 
Diphtheria  is  rarely  confined  to  the 
larynx  when  the  time  for  intubation  or 
tracheotomy  is  reached.  Tracheal  de- 
tached membrane  is  the  greatest  danger 
of  intubation;  the  expiration  is  suddenly 
arrested  by  closure  of  lower  end  of  tube. 
Hence  the  length  of  the  latter.  Bayeux's 
claim  for  short  tubes  is  theoretical,  ex- 
cept in  statement  that  they  can  be  ex- 
pelled by  pressure  from  outside, — a 
method  frequently  employed  in  the 
United  States.  Cheatham  claims  to  have 
been  first  in  its  adoption.  Joseph 
O'Dwyer,  Assoc.  Ed.,  Annual,  '96.] 

Case  of  sudden  death,  on  reinsertion 
of  tube,  from  tracheal  cast  pushed  down 
by  tube,  after  removal  on  seventh  day. 
Evans  (Archives  of  Pediatrics,  Mar.,  '95). 

[Death,  in  such  cases,  may  be  due  to 
(1)  asphyxia;  (2)  pushing  down  of 
membrane;  (3)  making  false  passage, 
beginning  in  ventricle.  The  latter  is 
more  liable  to  occur,  at  the  end  of  the 
week,  on  reintroduction,  through  pre- 
vious obliteration  of  the  ventricle  by 
pseudomembrane,  etc.  Practice  in  ca- 
daver, where  the  ventricles  are  avoided 
with  difficulty,  is  recommended.  It  can 
only  occur  when  the  patient's  head  is 
thrown  too  far  back,  bringing  the  lower 
end  of  the  tube  against  the  anterior 
laryngeal  wall.  Joseph  O'Dwyer,  Assoc. 
Ed.,  Annual,  '96.] 

Death  a  few  minutes  after  intubation 
in  case  treated  with  antitoxin.  Supposed 
to  be  due  to  bulbar  reflex.  Duran  (Amer. 
Jour.  Med.  Sciences,  June,  '95). 

[Convulsions  are  usually  due  to  partial 
asphyxia  from  prolonged  attempts  to  in- 
tubate, and  to  uraemia.  Illustrative  case, 
in  which  high  temperature  (107°  F.)  was 
found  to  be  cause  of  convulsions.  Joseph 
O'Dwyer,  Assoc.  Ed.,  Annual,  '96.] 

Accidental  swallowing  of  tube  in  4 
cases  out  of  122.  Two  of  the  children 
passed  the  tubes, — 1  in  two  days,  the 
other  in  three  days.    The  other  2  died 


from  disease;  one  tube  found  in  the 
stomach,  the  other  in  the  caecum.  Variot 
(L'Union  Med.,  July  13,  '95). 

[If  properly  placed  and  string  removed, 
unusually  large  percentage  of  accidents. 
In  only  2  out  of  almost  500  personal 
cases  were  tubes  coughed  out  or  swal- 
lowed. Joseph  O'Dwyer  Assoc.  Ed., 
Annual,  '96.] 

Literature  of  '96-'97-'98. 

Importance  demonstrated  on  regulat- 
ing the  size  of  the  tube  in  accordance 
with  the  size,  and  not  the  age,  of  the 
child.  Glover  (Jour,  of  L.,  R.,  and  0., 
Mar.,  "98). 

O'Dwyer's  tube  seems  occasionally  to 
be  productive  of  laryngeal  stenosis.  The 
majority  of  cases  of  stenosis  occurred  in 
children  who  had  expelled  the  tube  fre- 
quently during  the  treatment  of  their 
laryngeal  or  other  trouble.  Some  of 
these  stenoses  were  seated  below  the 
glottis;  others,  and  they  were  the 
gravest,  were  situated  at  the  level  of 
the  cricoid  cartilage,  where  the  larynx 
is  narrowest.  Repeated  expulsions  of  the 
tube  are  symptomatic  of  laryngeal  ul- 
ceration of  the  cricoid  region  of  the 
larynx.  This  region  should  serve  as  the 
gauge  for  the  size  of  the  tube  to  be  used 
which  would  vary  according  to  the 
child's  age.  Bokai,  Heubner,  Boulay, 
Sevestre  (Twelfth  Intern.  Congress  of 
Surgery;  N.  Y.  Med.  Jour.,  Oct.  16,  '97). 

In  case  there  is  long-continued  neces- 
sity for  the  use  of  the  tube,  what  can  be 
done?  After  removing  the  tube  on  the 
fourth  or  fifth  day,  if  the  dyspnoea  re- 
turns, a  smaller  tube  should  be  intro- 
duced instead  of  the  one  removed.  This 
in  turn  should  not  remain  longer  than 
two  days  without  being  removed,  pro- 
viding it  has  not  been  previously  ex- 
pelled. If  the  d}'spnoea  still  returns,  in- 
troduce a  still  smaller  tube.  The  eirort 
should  now  be  to  use  the  smallest  tube 
that  will  be  retained.  This  method,  to- 
gether with  the  free  administration  of 
sfrychnine,  offers  the  greatest  hope  of 
promptly  overcoming  the  difficulty. 


INTUBATION. 


MODIFICATION  OF  O'DWYER'S  INSTRUMENTS. 


175 


Modifications  of  O'Dwyer's  Instru- 
ments.— The  instruments  as  fully  per- 
fected by  Dr.  O'Dwyer  have  been  modi- 


Fig.  17. 


fied  by  various  operators;  some  of  these 
modifications  are  questionable  improve- 
ments, while  some  undoubtedly  possess 


head,  and  a  thimble,  with  hook  attached, 
which  he  used  on  the  index  finger  of  the 
right  hand.     Having  never  used  this 
|  method,  I  cannot  speak  of  its  merits. 
Another  modification  has  been  devised 
by  Ferroud,  aiming  to  make  one  instru- 
|  ment  answer  for  both  extractor  and  in- 
j  troducer;  his  instruments  have  been  still 
I  further  modified  and  simplified. 

Modification  of  usual  instruments  so 
as  to  make  one  instrument  serve  for  in- 
troduction and  extraction  of  tubes,  ex- 
tractor having  much  shorter  curve. 
Egidi  (II  Policlinico,  vol.  i,  No.  35,  '95). 

[A  single  instrument  cannot  be  con- 
structed to  satisfactorily  serve  both  pur- 
poses.   If  tubes  are  long,  the  curve  of 


Fig.  18. 


advantages.  The  main  idea,  however,  re- 
mains unchanged;  and,  however,  greatly 
the  instruments  may  be  altered,  the  fame 
of  the  great  and  original  inventor  will 
never  be  dimmed.  In  this  connection 
reference  will  be  made  to  only  a  few  of 
these  modifications. 

The  writer,  in  the  early  history  of  the 
operation  finding  the  original  gag  (Fig. 
17)  inconvenient  on  account  of  its  strik- 
ing the  shoulder,  had  one  constructed 
(Fig.  18)  to  extend  backward  instead  of 
downward,  thus  overcoming  this  objec- 
tion. This  gag  answers  well  all  require- 
ments. The  gag  has  also  been  modified 
by  others,  notably  by  Henrotin  (Fig.  19) 
and  Allingham  (Fig.  20).  An  ingenious 
method  of  overcoming  the  difficulty  of 
extracting  the  tube  was  devised  by  Dr. 
Dillon  Brown,  of  New  York.  Tt  consists 
of  a  tube,  with  small  ring  attached  to  the 


the  introducer  must  be  short,  else  the 
difficulty  of  entering  the  larynx  is  in- 
creased; tubes  cannot  be  removed  with 
short-curved  extractor  except  in  very 
young  children.  Joseph  O'Dwyer, 
Assoc.  Ed.,  Annual,  '96.] 


Fig.  19. 


The  writer  some  six  years  ago,  with 
the  assistance  and  co-operation  of  Charles 


176 


INTUBATION.    MODIFICATION  OF  O'DWYER'S  INSTRUMENTS. 


Truax  &  Co.,  of  Chicago,  devised  a  set  of 
instruments  differing  in  many  particu- 
lars from  those  of  O'Dwyer,  the  domi- 
nant idea,  however,  being  the  same.  The 
aim  was  to  insure  more  perfect  disinfec- 


same  purpose.  These  instruments  are 
simple,  uncomplicated,  and  efficient. 

Improved  intubator  for  the  relief  of 
laryngeal  stenosis.  The  tubes  are  cor- 
rugated and  act  as  a  self-retaining  device, 


Fig.  20. 


tion.  The  obturator  has  no  joint  and  is 
not  screwed  upon  the  instrument,  but  is 
a  plain  band  of  steel  solidly  attached  to 
the  introducer.  Moreover,  the  instru- 
ment, which  consists  of  only  two  plain 
pieces  of  metal,  can  be  easily  separated. 
There  are  no  crevices  in  which  septic 
matter  can  be  concealed.  The  tubes  are 
the  same  as  in  the  O'Dwyer  set.   The  gag 


being  much  less  easily  ejected;  they  are 
made  of  vulcanized  Para  rubber,  the  best 
and  purest  obtainable.  The  length  is 
the  same  as  O'Dwyer's.  They  are  made 
large  in  the  centre.  The  introducer  is 
so  constructed  that  the  lumen  of  the 
tube  is  never  occluded.  L.  Fischer  (Med. 
Record,  June  20,  '97). 

Instrument  personally  designed  com- 
bines the  offices  of  extractor  and  intro- 
ducer.  It  has  at  its  distal  extremity  two 


Fig.  21. 


is  constructed  so  as  to  insure  unlocking 
of  the  blades  for  purposes  of  disinfec- 
tion. The  extractor  (Fig.  26)  is  also  so 
constructed  that  the  three  parts  of  which 
it  is  made  can  easily  be  separated  for  the 


serrated  beaks  about  two  inches  long. 
They  are  opened  by  a  pressure  with  the 
thumb  upon  a  lever,  and  are  automatic- 
ally held  open  by  a  ratchet  arrangement, 
while  pressure  with  the  index  finger  upon 
the   lower  end   of   this  ratchet-bar  re- 


INTUBATION.    COMPARATIVE  VALUE. 


177 


lieves  it  and  closes  the  beaks.  By  firm 
pressure  the  beaks  hold  the  tube  immov- 
ably. The  tubes  themselves  are  also 
slightly  modified,  the  upper  opening 
being  funnel-shaped  to  facilitate  the  in- 
troduction of  the  beaks  when  the  tube 
is  in  the  larynx,  and  the  lower  end  being 
cut  off  at  an  angle  of  forty-five  degrees, 
inclining  from  right  to  left.  This  facili- 
tates the  passage  of  the  tube  between 
the  vocal  cords.  Max  Thorner  (Cincin- 
nati Lancet-Clinic,  Feb.  19,  '98). 


ing  of  the  American  Medical  Association, 
Section  of  Pediatrics)  in  which  antitoxin 
was  employed  in  conjunction  with  in- 
tubation, there  were  38  recoveries,  or  95 
per  cent.  Such  a  record  I  am  convinced 
has  never  been  reached  by  a  single  oper- 
ator with  tracheotomy  in  private  prac- 
tice. 

The  following  tables  of  my  cases  well 
illustrate  the  success  that  followed  in- 


Fig.  22. — Thorner's  combined  introducer  and  extractor. 


Comparative  Value  of  Intubation. — 

The  weight  of  evidence,  nowadays,  as 
compared  to  tracheotomy  is  in  favor  of 
intubation  as  a  life-saving  operation. 
Out  of  543  cases  in  which  I  have  per- 
formed intubation,  all  in  private  practice, 
I  obtained  215  recoveries,  or  39.79  per 
cent.  In  my  last  143  cases,  there  were  76 
recoveries,  or  53.14  per  cent.  In  the  40 
cases  (fully  reported  at  the  Denver  meet- 


creasingly  the  gradual  development  of 
the  operation,  and  the  wonderful  results 
of  the  operation  when  aided  by  the  use 
of  antitoxin. 

Fiest  Hundred  Cases. 


Age. 
Under  1  year 
1  vear 


No. 

Cases. 

.  5 
.13 


Re-  Per- 

coveries.  centage. 

1  20.00 

2  15.38 


INTUBATION.    COMPARATIVE  VALUE. 


2  years .  . 

.  .22 

4 

18.18 

3  years .  . 

.17 

2 

17.76 

4  years . . 

.  .15 

7 

46.66 

5  years.  . 

.  9 

3 

33.33 

0  years .  . 

.  D 

o 

to 

7  years.  . 

.  8 

2 

25.00 

8  years .  . 

.  4 

3 

75.00 

9  years.  . 

.  1 

1 

100.00 

10  years.  . 

.  1 

0 

c\i\  (\r\ 

100 

27 

27.00 

Second  One 

Hundred 

Cases. 

No. 

Re 

Per- 

Age. 

Cases. 

coveries.  centage 

1 

17 

5 

29.81 

2 

15 

2 

13.33 

3 

14 

4 

28.56 

4 

years  

22 

■7 

31.81 

5 

years  

9 

6 

66.66 

6 

vears  

8 

3 

37.50 

7 

6 

4 

66.66 

8 

years  

1 

1 

100.00 

9 

years  

3 

2 

66.66 

10 

years  

1 

0 

00.00 

1  9 

I/O 

2 

0 

00.00 

13 

1 

0 

00.00 

14 

1 

0 

00.00 

100 

34 

34.00 

Third  One 

Hundred 

Cases. 

No. 

Re- 

Per- 

Age. 

Cases. 

coveries,  centage 

Under  1  year  .  .  . 

.  5 

2 

40.00 

1  year  .  . . 

.11 

2 

18.18 

2  years .  . . 

.13 

5 

38.46 

3  3'ears. . . 

.19 

11 

57.72 

4  years . . . 

.22 

9 

40.90 

5  years . .  . 

.10 

5 

50.00 

6  years .  .  . 

.  7 

1 

14.28 

7  years . .  . 

.  6 

3 

50  00 

8  years.  .  . 

.  2 

0 

00.00 

9  years . . . 

.  2 

0 

00.00 

1 0  years .  .  . 

.  1 

1 

100.00 

20  years. 

.  .  .  1 

0 

00.00 

43  years. 

.  .  .  1 

1 

100.00 

100 

40 

40.00 

Fourth  One  Hundred  Cases. 

No. 

Re- 

Per- 

Age/ 

Cases. 

coveries. 

centage. 

Under  1  year  . 

.  .  .  2 

1 

50.00 

1  year  . 

.  .  .11 

3 

27.27 

2  years. 

.  .20 

7 

35.00 

3  years. 

.  .19 

10 

52.63 

4  years . 

.  .20 

7 

35.00 

5  years. 

.  .11 

4 

36.36 

6  years. 

.  .  5 

1 

20.00 

7  years. 

.  .  5 

1 

20.00 

8  years. 

.  .  3 

2 

66.66 

10  years. 

.  .  2 

1 

50.00 

11  years. 

.  .  1 

1 

100.00 

60  years. 

.  .  1 

0 

00.00 

100 

38 

38.00 

The  Last  One  Hundred  axd 

FORTY- 

three  Cases. 

No. 

Re- 

Per- 

Age. 

Cases. 

coveries. 

centage. 

Under  1  year  .  . 

.  .  2 

0 

00.00 

1  year  .  . 

.  .19 

7 

36.84 

2  years.  . 

.  .28 

22 

78.57 

3  years .  . 

.  .35 

17 

48.57 

4  years.  . 

.  .20 

11 

55.00 

5  years .  . 

..  9 

4 

44.44 

6  years. . 

.  .  9 

8 

88.88 

7  years.  . 

..  8 

2 

25.00 

8  years . . 

.  .  5 

4 

80.00 

9  years .  . 

.  .  1 

0 

00.00 

10  years. . 

2 

1 

50.00 

12  years. . 

2 

0 

00.00 

13  years. . 

.  .  1 

0 

00.00 

17  years. . 

..  1 

0 

00.00 

36  years. . 

..  1 

0 

00.00 

143 

76 

53.14 

INTUBATION.    COMPARATIVE  VALUE. 


179 


The  Last  Forty  Cases. 


No.  Re-  Per- 

Age.           Cases,  coveries.  centage. 

1  year                   5  4  80.00 

2  years  12  12  100.00 

3  years                  6         6  100.00 

4  years                  6         5  83.33 

5  years                 2         2  100.00 

6  years                 7         7  100.00 

7  years                  1         1  100.00 

8  years                 1         1  100.00 


40       38  95.00 

An  agent  which  would  arrest  the  pro- 
gressive descent  of  the  diphtheritic  proc- 
ess from  the  larynx  into  the  bronchi  and 
hasten  the  disappearance  of  the  obstruct- 
ive exudate  is  just  what  was  needed  to 
make  intubation  the  ideal  operation  for 
the  relief  of  the  great  majority  of  cases 
of  croup  requiring  operative  interference. 
Such  an  agent  we  now  possess  in  anti- 
toxin for  a  large  group  of  cases,  and  we 
are  not  surprised,  therefore,  to  find  that 
the  employment  of  intubation  as  a  sub- 
stitute for  tracheotomy,  has  been  con- 
siderably extended  by  the  introduction 
of  serum-therapy.  W.  H.  Welch  (Trans. 
Assoc.  of  Amer.  Phys.,  vol.  x,  '95). 

Two  thousand  three  hundred  and 
sixty-eight  cases  of  intubation  collected 
from  the  reports  of  166  operators,  with 
647,  or  27  3/10  per  cent.,  recoveries.  Dillon 
Brown  (N.  Y.  Med.  Jour.,  Mar.  9,  '89). 

Two  thousand  four  hundred  and 
seventeen  tracheotomies  performed  for 
croup,  with  586  recoveries,  or  24.2  per 
cent.,  and  5546  intubations,  with  1691 
recoveries,  or  30.5  per  cent.  George  Mc- 
Naughton  and  William  Maddern  (Brook- 
lyn Med.  Jour.,  Aug.,  '93). 

Collective  investigation  on  intubation 
in  Germany,  gives  an  aggregate  of  1445 
<  ;iscs  intubated  for  the  relief  of  croup, 
with  553  recoveries,  or  38  per  cent. 
Ranke  (Miinch.  med.  Woch.,  No.  44.  '93). 

The  results  in  tracheotomy  are:  in 
15,995  cases,  4816  recoveries,  or  30.18  per 
cent.;  in  intubation,  8299  cases,  with 
2486  recoveries,  or  29.97  per  cent.  In 
7(19  cases  of  intubation  secondary  tra- 


cheotomy has  been  practiced  136  times 
as  a  last  resource,  and  has  given  ten 
cures.  Gillet  (Gaz.  des  Hop.,  Mar.  5, 
'94). 

Literature  of  '96-'97-'98. 

Twenty-six  cases  of  intubation  for 
croup  in  a  country  practice,  with  a 
mortality  of  30  per  cent.  Abarnon 
(These  de  Paris;  Pediatrics,  May  15,  '98). 

I  fully  believe  that  when  antitoxin  is 
given  early  and  properly  and  energetic- 
ally employed  in  full  doses  and  repeated 
that  the  disease  is  at  once  cut  short  and 
that  no  further  progress  occurs.  Again, 
I  am  fully  convinced  that  if  a  patient 
dies  after  intubation  from  bronchial  ob- 
struction due  to  the  presence  of  diphthe- 
ritic exudation,  that  the  remedy  has 

either  been  used  late,  the  extension 

... 

having  taken  place  before  its  administra- 
tion, or  that  it  has  been  used  with  a  hesi- 
tating hand  and  in  insufficient  dosage  or 
that  the  preparation  has  been  of  uncer- 
tain strength.  The  normal  prognosis  in 
diphtheritic  or  membranous  croup,  is  so 
fatal  that  hesitation  in  the  use  of  anti- 
toxin is  almost  criminal.  A  full  dose  of 
2000  units  should  be  given  to  a  child 
and  half  the  strength  for  infants,  repeat- 
ing or  even  doubling  the  dose  in  twelve 
or  sixteen  hours.  It  should  be  given  in 
full  doses  and  be  repeated  once,  twice,  or 
thrice,  if  necessary. 

O'Dwyer  has  stated  that  acute  non- 
traumatic stenosis  of  the  larynx  in  chil- 
dren that  endangers  life  by  suffocation  is, 
with  rare  exceptions,  diphtheria.  This 
disease,  if  unrelieved  by  mechanical 
means,  proves  fatal  in  about  90  per  cent, 
of  the  cases,  and,  with  all  the  aid  that 
medicine  and  surgery  can  afford,  it  still 
continues  to  be,  with  few  exceptions,  the 
most  fatal  of  all  acute  diseases.  In  con- 
trast to  this  statement  it  may  now  be 
said  that  as  a  result  of  the  early  and  free 
use  of  antitoxin,  aided  by  properly  per- 


180 


IODINE.    PREPARATIONS  AND  DOSES. 


formed  intubation,  death  from  this  dis- 
ease should  rarely  occur. 

F.  E.  Waxham, 

Chicago. 

INTUSSUSCEPTION.  See  Obstruc- 
tion, Intestinal. 

IODINE,  IODOFORM,  AND  OTHER 
DERIVATIVES. — Iodine,  obtained  from 
the  ashes  of  sea-weeds  and  from  crude 
Chilean  saltpeter,  occurs  in  the  form  of 
bluish-black  scales.  It  gives  off  a  char- 
acteristic violet  vapor  and  emits  an  acrid 
and  unpleasant  odor  when  burned.  Io- 
dine was  discovered  by  Court ois  in  1812 
in  sea-salt.  It  is  not  found  in  its  pure 
state  in  Nature,  being  combined  with 
potassium  or  sodium  in  marine  plants, 
which  absorb  it  from  their  surround- 
ings. Iodine  melts  at  107°  C,  but  vola- 
tilizes completely  at  175°  C.  It  gives  off 
fumes  at  ordinary  temperature.  It  is  but 
slightly  soluble  in  water  (1  part  in  about 
7000),  but  is  very  soluble  in  alcohol  and 
glycerin. 

Iodine  imparts  a  dark-yellow  or  brown 
color  to  all  substances  over  which  it  is 
lightly  applied,  but  wherever  starch  is 
present  the  coloring  is  blue.  This  prop- 
erty to  color  starch  blue  is  so  marked  that 
it  serves  as  the  basis  of  various  tests  that 
make  it  possible  to  detect  iodine  in  about 
four  hundred  and  fifty  thousand  times  its 
weight  of  water.  Its  detection  in  urine 
is  greatly  facilitated  by  allowing  a  por- 
tion of  the  liquid  to  evaporate;  the  addi- 
tion of  a  few  drops  of  nitric  acid  serves 
to  insure  the  liberation  of  any  iodine  that 
may  be  present  in  combination  with 
oilier  elements. 

In  estimating  the  iodides  in  the  urine, 
the  decomposition  of  these  salts  by  chlo- 
rine may  be  employed.  Two  and  one- 
half  drachms  of  urine  are  taken,  and  an 
equal  quantity  of  hydrochloric  acid  and  i 
2  or  3  drops  of  chlorine-water  added.    A  ' 


brown  color  appears,  which  is  changed 
to  blue  by  the  addition  of  starch-water. 
For  quantitative  estimation  the  urine  is 
evaporated  and  charred  and  the  char 
burned  off.  The  residue  is  taken  up 
with  water  acidulated  with  nitric  acid, 
and  nitrate  of  silver  added  to  excess. 
The  precipitate  consists  of  the  chloride 
and  iodide  of  silver.  It  is  collected, 
dried,  and  weighed,  and  then  subjected 
to  chloridization,  as  above.  The  differ- 
ence in  weight,  due  to  the  transforma- 
tion of  the  iodide  into  the  chloride,  is 
the  basis  for  calculation  of  the  quantity 
of  iodine  in  the  primary  precipitate. 
Jolles  (Zeit.  f.  anal.  Chemie,  B.  30,  p.  288, 
'91). 

Attention  called  to  a  source  of  failure 
in  recognizing  the  presence  of  iodine  in 
an  ammoniaeal  urine,  which  must  be  of 
considerable  importance.  When  one  adds 
strong,  fuming  nitric  acid  to  the  urine 
containing  an  iodide  the  iodine  is  freed, 
and  is  usually  recognized  by  solution 
with  a  purplish  color  in  chloroform.  If, 
however,  the  urine  contains  ammoniaeal 
compounds  this  reaction  may  be  quite 
different.  The  iodine  reacts  upon  the 
ammonia  salts,  and  is  formed  into  nitric 
iodide  and  hydriodic  acid  (XH3-f-6I  = 
XI3  +  3HI).  This  substance  is  very  un- 
stable, and  in  decomposing  forms  iodic 
acid,  hydriodic  acid,  and  nitrogen  (4XI3 
+  3H26  =  GHI  +  3LO  +  4X) .  Thus,  one 
may  entirely  fail  to  get  the  character- 
istic chloroform  solution.  To  such  a 
urine  caustic  potash  should  be  added  to 
replace  the  ammonia,  in  order  thai  this 
mistake  be  avoided.  Gillet  (Annales  de 
la  Polyelinique,  Oct.,  79lj. 

Literature  of  '96-'97-'98. 

Attention  again  called  to  the  use  of 
iodine  as  a  test  for  bile.  The  reagent  is 
a  dilute  tincture  of  iodine,  of  a  bright 
mahogany  color.  The  test  is  made  by 
allowing  the  iodine  to  run  into  an  in- 
clined test-tube  containing  the  suspected 
fluid,  and  in  the  presence  of  bile  forms 
a  grass-green  ring  at  the  point  of  con- 
tact. Kosin  (Wiener  klin.  Woch.,  Xo. 
11.  '98). 

Preparations  and  Doses. — Iodine  is  not 
employed  in  solid  form.    The  prepara- 


IODINE.    PHYSIOLOGICAL  ACTION. 


181 


tions  generally  utilized  are  the  follow- 
ing:— 

Tincture  of  iodine  is  a  7-per-cent.  solu- 
tion in  alcohol.  It  is  not  used  internally 
because  the  iodine  is  precipitated  by  the 
gastric  juices.  It  should,  therefore,  only 
be  employed  for  topical  applications.  A 
decolorized  tincture  has  been  made  and 
used,  but  it  contains  no  iodine,  and  is 
worthless. 

Compound  solution  of  iodine  (Lugol's 
solution).  This  is,  by  far,  the  best  prep- 
aration of  iodine  for  internal  use.  It 
contains  5  per  cent,  of  iodine  and  10  per 
cent,  of  iodide  of  potassium.  Dose,  3  to 
15  drops,  largely  diluted. 

Ointment  of  iodine  contains  4  per  cent, 
of  iodine,  1  per  cent,  of  iodide  of  potas- 
sium, 2  per  cent,  of  water,  and  93  per 
cent,  of  benzoated  lard. 

Potassium  iodide,  white  colorless  crys- 
tals, slightly  bitter  saline  taste,  soluble  in 
water  and  alcohol.  Dose,  5  to  30  grains, 
but  well  diluted. 

Potassium  iodide  is  better  borne  if  it 
is  given  immediately  before  eating,  but 
it  may  be  administered  during  or  after 
a  meal  to  avoid  its  coming  in  contact 
with  the  mucous  membrane  of  the  stom- 
ach and  so  being  absorbed  too  rapidly. 
Editorial  (N.  Y.  Med.  Jour.,  Sept.  1,  "94). 

Potassium  iodide  should  not  be  ad- 
ministered soon  after  a  meal,  since  the 
iodine  will  form  the  inert  iodide  of 
starch . 

Sodium  iodide;  same  properties  as  the 
iodide. 

Iodide  of  sodium  preferred  to  that  of 
potassium  on  the  ground  that  it  is  less 
apt  to  produce  nausea,  loss  of  appetite, 
and  emaciation.  It  also  contains  more 
iodine  in  the  proportion  of  10  to  9.  R. 
Cory  (Brit.  Med.  Jonr.,  May  20,  '88). 

The  only  substitute  for  iodide  of  potas- 
sium which  has  given  satisfaction  is  the 
iodide  of  rubidium.  While  possessing 
the  same  advantages  as  the  iodide,  it  is 
riot  as  unpleasant  to  the  taste  and  is  bet- 


ter tolerated.  The  dose  and  its  indica- 
tions in  therapeutics  are  the  same. 

The  new  product — iodide  of  rubidium 
— is  better  tolerated  than  iodide  of  po- 
tassium. Neisser  (Ther.  Monats.,  No.  5, 
'94). 

Iodide  of  rubidium  preferred  in  syph- 
ilis. LeistikofT  (Monats.  f.  prak.  Derm., 
No.  10,  '93). 

Iodide  of  rubidium  was  well  borne  by 
three  patients  who  could  not  tolerate 
iodide  of  potassium.  It  is  applicable  in 
cases  where  a  prolonged  treatment  with 
iodine  in  small  doses  could  not  be  insti- 
tuted on  account  of  the  individual  sus- 
ceptibility of  the  patient.  Vogt  (Revue 
Gen.  de  Clin,  et  de  Ther.  Jour,  des  Pract., 
May  19,  '94). 

Literature  of  '96-'97-'98. 

Series  of  experiments  demonstrating 
the  great  value  of  iodide  of  rubidium  as 
a  substitute  for  the  iodide  of  potassium 
or  sodium.  In  syphilis  it  restores  haemo- 
globin, increases  the  number  of  blood- 
corpuscles,  and  increases  the  body- 
weight.  Colombini  and  Pasquini  (Jour, 
des  Prat.,  Oct.  15,  '98). 

Solution  of  arsenic  and  mercuric  io- 
dide (Donovan's  solution)  contains  1  per 
cent,  each  of  the  arsenic  iodide  and  the 
mercuric  iodide.  Dose,  1  to  8  drops,  well 
diluted. 

Ammonium  iodide;  colorless  plates, 
having  a  bitter  taste.  Similar  to  iodide 
of  potassium.  Dose,  3  to  5  grains,  well 
diluted. 

Strontium  iodide;  colorless  plates; 
bitter  saline  taste;  become  yellow  on  ex- 
posure to  the  air.  Soluble  in  hot  and 
cold  water.  Similar  to  the  iodide,  but 
thought  to  be  less  irritating  to  the  in- 
testinal tract.  Dose,  5  to  10  grains  well 
diluted. 

Physiological  Action. — When  applied 
to  the  sl<in,  iodine  turns  it  a  yellowish 
brown.  At  first  it  acts  as  a  slight  irri- 
tant, but  when  the  applications  are  too 
frequently  repeated,  or  the  preparation 


182 


IODINE.    PHYSIOLOGICAL  ACTION. 


is  too  concentrated,  the  superficial  struct- 
ures may  undergo  a  process  of  active  in- 
flammation, which  usually  subsides,  how- 
ever, when  the  applications  are  stopped. 

When  taken  internally,  iodine,  as  well 
as  its  salts,  is  eliminated  by  the  kidneys, 
and  tends  to  irritate  these  organs  when 
large  doses  are  administered.  At  first 
the  flow  of  urine  is  increased;  later  on  it 
is  decreased,  and  the  proportion  of  urea 
may  also  be  greatly  diminished.  It  fre- 
quently causes  albuminuria,  and  ne- 
phritis has  been  ascribed  to  the  influence 
of  the  iodides,  but  the  evidence  that  ne- 
phritis was  not  already  present  before 
the  administration  of  the  remedy  has  not 
been  made  clear  in  the  cases  reported. 
Notwithstanding  Haig's  view  to  the  con- 
trary, increase  of  the  products  of  metab- 
olism, urea,  etc.,  in  the  urine,  has  been 
noted  by  many  observers,  and  it  is  prob- 
able that  contracted  kidney,  a  condition 
now  known  to  be  present  in  most  cases, 
in  part  accounts  for  Dr.  Haig's  views. 
See  and  other  observers  have  claimed 
that  iodine  accumulates  in  the  system, 
and  that  its  elimination  occurred  irregu- 
larly. Kiiss  ascribes  to  this  fact  the  ma- 
jority of  the  deleterious  symptoms  often 
attending  its  use. 

Urine  of  patients  of  both  sexes  and  all 
ages  analyzed.  The  amount  of  iodide 
of  potassium  eliminated  in  the  urine 
was  increased  in  proportion  to  the  dose 
administered.  Observation  demonstrated 
the  fact  that  symptoms  of  iodism,  when 
they  appeared,  were  caused  by  the  re- 
tention of  iodide  of  potassium  in  the 
system.  They  occurred  when  only  half 
the  amount  given  had  been  eliminated. 
In  cases  where  doses  of  20  grains  are 
administered  iodide  of  potassium  is  elim- 
inated in  the  proportion  of  7~>  per  cent. 
There  is  no  danger  to  the  system,  pro- 
vided the  excretive  power  be,  to  some 
extent,  normal.  Doses  containing  more 
than  20  grains  seem  to  be  incompletely 
absorbed.  Ehlers  (London  Medical  Rec, 
Sept.,  '89). 


Arterial  tension  varies  with  the  uric 
acid  that  is  circulating  in  the  blood. 
Some  twenty  drugs,  or  rather  groups  of 
drugs,  all  diminish  the  excretion  of  the 
uric  acid  in  the  urine,  and  at  the  same 
time  produce  also  relaxed  arterioles, 
lowered  arterial  tension,  and  diuresis. 
Iodides  can  be  classed  with  these  drugs. 
This  action  of  iodides  on  the  solubility 
of  the  urates,  and  so  on  the  contraction 
of  the  arterioles,  enables  us  to  explain 
all  their  most  important  effects  in  phys- 
iology and  pathology.  A.  Haig  (Brit. 
Med.  Jour.,  Jan.  14,  '93). 

Case  in  which  a  man  with  traumatic 
periostitis  of  the  tibia  was  given  iodide 
of  potash.  In  addition  to  the  usual 
symptoms  of  iodine  poisoning  there  was 
a  large  albuminuria,  with  fatty  and 
granular  casts.  No  iodine  was  found  in 
the  urine,  which  had  a  specific  gravity 
of  1026  and  a  dark  color.  Gerson 
(Munch,  med.  Woch.,  June  1,  '89). 

Iodine,  according  to  Kiiss,  accelerates 
the  cardiac  action  in  persons  in  whom 
the  circulation  is  quiet.  Haig,  as  shown, 
connects  the  arterial  tension  with  the 
amount  of  uric  acid  circulating  in  the 
blood.  The  majority  of  authors  recog- 
nize the  existence  of  dilatation  of  the 
capillaries  and  smaller  blood-vessels,  but 
the  reports  upon  this  point  are  exceed- 
ingly contradictory.  A  general  retro- 
spect of  the  views  advanced  would  tend 
to  show  that  the  quantity  administered 
has  much  to  do  with  the  problem,  large 
doses  tending  to  increase  arterial  press- 
ure. 

Iodized  water  and  solutions  of  iodine 
or  iodides  do  not  affect  the  blood- press- 
ure when  injected  into  the  veins.  Solu- 
tions of  iodide  of  potassium,  introduced 
in  the  same  manner,  act  like  potassium 
and  increase  it.  In  larger  doses  they 
provoke  a  fall  in  blood-pressure.  Iodide 
of  sodium  proves  less  dangerous  in  this 
respect,  and  in  large  doses  produces  a 
temporary  increase  of  pressure,  followed 
by  a  period  of  gradual  diminution.  The 
effects  of  lite  iodides  in  the  treatment 
of  arteriosclerosis  may  possibly  be  ex- 
plained by  their  beneficial  influence  on 


IODINE. 

general  nutrition.  Prevost  and  Binet  J 
(London  Med.  Recorder,  Sept.,  '90). 

Study  of  the  effects  of  iodide  of  potas- 
sium upon  the  blood  of  fifteen  patients 
and  four  healthy  persons  before  and  after 
taking  iodide  of  potassium.  The  effect 
of  the  medicament  in  doses  of  from  15 
to  30  grains  a  day  on  non-syphilitic 
patients  and  on  healthy  persons  is,  dur- 
ing the  first  two  or  three  days  of  its  ad- 
ministration, to  increase  the  number  of 
young  corpuscles  and  to  diminish  the 
number  of  overmature  white  corpuscles 
in  the  blood,  and,  at  the  same  time,  to 
increase  the  number  of  those  breaking 
up.  As  to  the  total  number  of  corpuscles 
per  cubic  millimetre,  the  effect  of  the 
iodide  appears  to  be  to  cause  an  increase, 
but  a  slight  one.  Administered  to  syph- 
ilitic patients,  the  iodide  produces  an 
increase  in  the  number  of  overmature 
elements  and  a  decrease  of  the  immature 
white  corpuscles  and  those  which  are 
breaking  up.  T.  V.  Ishumin  (Inaug. 
Dissert.,  No.  120,  '94). 

Iodide  of  potassium  dilates  the  vessels 
somewhat  more  than  does  digitaline,  and 
increases  considerably  the  peripheral  cir- 
culation, as  well  as  the  circulation  of  the 
arteries  which  supply  nourishment  to  the 
heart.  G.  See  (La  Med.  Moderne,  July 
2,  '91). 

Literature  of  '96-'97-'98. 

The  iodides  given  in  relatively  small 
doses,  three  or  four  times  daily,  and  con- 
tinued for  many  months  and  even  years, 
have  the  power  to  retard,  modify,  and 
improve  subacute  and  chronic  inflamma- 
tory processes  in  connective  tissue  of 
parenchymatous  organs  like  the  kidneys, 
the  liver,  the  lungs,  and  particularly  so 
the  sclerotic  disease  of  the  arterial 
vessels.  It  appears  that  this  salutary 
effect  is  brought  about  by  direct  inhibi- 
tion of  the  proliferation  of  the  connect- 
ive tissue,  as  well  as  by  subsequent  in- 
duction of  disintegration  and  fatty 
metamorphosis  of  infiltrated  corpuscular 
elements  and  the  removal  of  the  same. 
It  is  reasonable  to  hold  that  the  drug 
manifests  and  develops  its  activity 
through  the  lymph-channels  and  spaces 
of  the  affected  organs  by  direct  action 
upon  the  irritating  substances,  by  stim- 


IODISM.  183 

ulating  the  vasomotor  nerves  and  in- 
creasing the  functional  activity  of  the 
parts.  The  favorable  influence  of  the 
iodides  can  be  clinically  demonstrated, 
and  is  more  decided  in  arterial  sclerosis 
than  in  similar  disease  of  parenchyma- 
tous organs,  and  will  show  itself  fre- 
quently, whether  the  underlying  cause 
is  gout,  alcoholism,  or  syphilis.  Leonard 
Weber  (The  Post-graduate,  Oct.,  '98). 

Iodism.  —  Coryza  and  profuse  dis- 
charge from  the  mucous  membrane  of 
the  upper  respiratory  tract,  ptyalism,  and 
an  acneiform  eruption  generally  starting 
over  the  shoulder-blades  constitute,  in 
the  majority  of  cases,  the  initiatory 
symptoms,  indicating  iodism.  This  may 
appear  after  a  few  doses  have  been  taken 
in  persons  who  possess  a  distinct  suscepti- 
bility to  the  drug,  but  in  the  majority  it 
is  not  until  the  dose  administered  has  be- 
come quite  great.  In  some  persons  small 
doses  are  more  likely  to  cause  iodism 
than  large  ones.  In  some  patients  the 
active  manifestations  are  much  more 
grave,  nausea,  diarrhoea,  and  marked 
frontal  headache  being  complained  of. 
The  skin-eruption  may  assume  many 
phases,  from  a  simple  acne  or  dermatitis 
to  eruptions  simulating  those  of  variola, 
varioloid,  purpura,  eczema,  etc. 

In  order  that  iodism  can  arise,  (1) 
nitrites  must  circulate  in  the  blood;  (2) 
the  reaction  on  the  mucous  membranes 
must  not  be  alkaline.  On  this  hypoth- 
esis there  are  three  indications  for 
treatment:  1.  To  attempt  to  combine 
the  free  iodine  again.  2.  To  remove  the 
nitrous  acid  at  the  moment  of  its  libera- 
tion from  the  nitrites.  3.  To  prevent 
the  formation  of  free  nitrous  acid.  4. 
No  way  of  accomplishing  this  purpose 
is  found.  5.  Nitrous  acid  is  destroyed 
by  sulphanilic  acid,  with  the  formation 
of  diazo-benzol-sulpho-nitrate,  as  asserted 
by  Ehrlich.  The  writer  tried  1  Va 
drachms  of  sulphanilic  acid  and  3A  to  1 
drachm  of  sodium  carbonate  in  5  fluid- 
ounces,  immediately  after  the  appearance 
of   iodism,   and   obtained   the  happiest 


IODINE. 


IODISM. 


results  in  a  number  of  eases,  thus  sup- 
porting Ehrlich's  views.  Two  and  one- 
lialf  to  3  drachms  of  sodium  bicarbonate 
are  given  within  twenty-four  hours  in 
two  doses.  It  was  found  that  when 
potassium  iodide  and  bicarbonate  of 
soda  were  given  simultaneously,  no 
symptoms  of  iodism  appeared,  but  iodism 
promptly  manifested  itself  on  the  with- 
drawal of  the  bicarbonate  of  soda.  Roh- 
mann  and  Malachowski  (Ther.  Monats., 
July,  '89). 

Case  of  a  man  who  took  16  grains  of 
potassium  iodide  per  diem  for  sixteen 
days.  Copious  watery  diarrhoea  set  in 
as  soon  as  the  drug  was  commenced, 
though  the  patient  suffered  previously 
from  habitual  slight  constipation,  and 
the  diarrhoea  persisted  during  the  ad- 
ministration of  the  drug,  ceasing  only 
when  it  was  discontinued.  The  patient 
was  much  reduced  in  weight,  but  quickly 
gained  flesh  when  the  iodide  was  stopped. 
The  drug  used  was  pure,  containing  no 
free  iodine  or  iodates.  D.  W.  Mont- 
gomery (Med.  News,  Dec.  29,  '94). 

In  acute  iodism  in  syphilis  the  head- 
ache may  reach  an  alarming  intensity; 
vomiting,  vertigo",  symptoms  of  cerebral 
compression,  delirium,  staggering  gait, 
somnolence,  and  coma  may  supervene. 
One  case  showed  alarming  depression  of 
the  heart's  action.  Neuralgias  of  the 
cerebral  nerves  often  occur.  These  symp- 
toms are  probably  due  to  an  increased 
cerebral  circulation  in  vessels  which  have 
undergone  specific  alterations.  The  best 
method  of  obviating  unpleasant  effects 
is  to  give  the  iodide  in  milk;  belladonna 
may  be  added,  as  well  as  potassium 
bromide.  E.  Finger  (Gazeta  Lekarska, 
No.  24,  '91). 

Literature  of  '96-'97-'98. 

Case  of  an  old  syphilitic  who  was  ab- 
solutely intolerant  of  the  potassium  salt, 
even  when  given  in  small  doses.  When 
90  grains  of  sodium  chlorate  were  given 
each  day  it  was  possible  to  administer 
45  grains  of  potassium  iodide  without 
any  untoward  symptoms.  This  was  con- 
tinued for  about  forty  days.  Calomen- 
opoulo  (Jour,  des  Prat.,  No.  18,  p.  288, 
'9G). 


When  any  of  the  preparations  of  iodine 
are  used  internally,  the  respiratory  tract 
should  be  watched  lest  dyspnoea  occur 
from  oedema  of  the  glottis.  This  is  espe- 
cially the  case  when  syphilis  is  present. 
The  likelihood  of  this  untoward  feature 
is  decreased  by  the  copious  use  of  drink- 
ing-water while  the  iodides  are  being 
taken. 

Series  of  nine  cases  collected  from  the 
literature  which  show  that  in  rare  cases 
the  internal  use  of  iodide  of  potassium 
may  suddenly  produce  such  intense 
oedema  of  the  glottis  as  to  render  neces- 
sary the  immediate  performance  of  tra- 
cheotomy. In  some  cases  the  oedema  is 
so  severe  as  to  produce  death,  although 
in  others  it  may  disappear  as  rapidly  as 
it  occurs.  It  was  shown  that  the  un- 
toward consequence  may  occur  soon  after 
the  injection  of  the  drug,  and  even  after 
small  doses.  Four  cases  presented  the 
oedema  on  the  first  day,  1  under  a  dose 
of  15  grains,  2  under  7 1/2  grains,  and 
the  fourth  under  as  small  a  dose  as  3 
grains.  Three  cases  showed  the  symp- 
toms on  the  second  and  the  eighth  on 
the  sixth  day,  after  doses  varying  from 
30  to  195  grains.  It  was  observed,  where 
oedema  occurred,  that  all  other  symp- 
toms of  iodism  were  absent,  and,  further, 
that  age  and  sex  had  no  influence;  that 
it  appeared  in  otherwise  perfectly 
healthy  persons,  and  that  after  the  dis- 
appearance of  the  oedema  persistence  in 
the  use  of  the  drug  produced  no  unfavor- 
able after-effects;  so  that  iodism  is  not 
a  permanent  symptom.  (Edema  of  the 
glottis,  fatal  in  a  few  minutes  if  not  re- 
lieved promptly,  may  supervene  on  the 
early  administration  of  the  drug,  and 
that  the  longer  the  salt  is  used,  the  less 
danger  is  there  of  oedema.  A.  Groenouw 
(Ther.  Monats..  Mar..  '90). 

Case  in  which,  some  days  after  the 
omission  of  the  iodide  of  potassium, 
which  had  been  given  for  the  treatment 
of  syphilis,  there  occurred  laryngeal 
oedema  with  stridor.  Eight  days  later 
the  affection  disappeared.  P.  Hermann 
(Jour,  of  Laryngology,  Feb.,  '92). 

Atrophy  of  the  mamma?  and  testicles 
has  been  observed  when  iodine  or  its 


IODINE.    PREVENTION  OF  IODISM. 


185 


salts  had  been  administered  for  a  long- 
time. Mental  disorders,  insomnia,  hypo- 
chondriasis, and  hysteria  have  also  been 
noted.  Peripheral  nervons  disorders — ■ 
such  as  neuralgia,  neuritis,  etc. — have 
occasionally  been  produced.  The  neural- 
gia is  sufficiently  severe  at  times  to  neces- 
sitate the  discontinuance  of  the  remedy. 
Kiiss  states  that  the  menstrual  flow  may 
assume  an  hemorrhagic  form.  Eapid 
emaciation  sometimes  results  from  the 
continued  use  of  iodine  or  its  prepara- 
tions. 

Two  unusual  cases  of  chronic  iodism. 
One  patient  was  an  hysterical  girl,  aged 
16,  whose  iodism  was  believed  to  result 
from  prolonged  and  incessant  inhalation 
of  sea-air.  The  other  patient  was  also 
a  woman,  aged  55,  one  of  a  family  of 
insane  persons.  In  her  case  the  iodism 
resulted  from  the  inunction  of  an  oint- 
ment of  iodide  of  potash.  In  both  cases 
there  was  emaciation  and  prostration, 
succeeded,  in  the  second  case,  by  fixed 
delusions  and  "melancholic  mania."  V. 
Gauthier  (Brit.  Med.  Jour.,  Mar.  23,  '89). 

Iodism  is  less  likely  to  occur  in  chil- 
dren than  in  adults.  The  chances  of 
iodism  are  decreased  when  the  patient  is 
careful  to  greatly  dilute  the  salt  taken. 

Attention  drawn  to  the  fact  that 
iodism  is  of  exceptional  occurrence  in 
children,  and,  the  younger  the  patient, 
the  less  is  the  liability  to  this  accident. 
J.  Comby  (La  Med.  Mod.,  July  10,  '95). 

The  absorptive  power  of  potassium 
iodide  and  sodium  salicylate  diminishes 
as  the  age  of  the  patient  advances,  and 
this  is  probably  due  to  the  different  con- 
dition of  the  vascular  system  existing 
at  different  ages.  K.  L.  Jatziita  (Inaug. 
Dissert.,  No.  12,  '90). 

Prevention  of  Iodism. — Probably  the 
best  remedy  we  have  is  Fowler's  solution; 
it  in  no  way  seems  to  interfere  with  the 
action  of  the  iodine  preparations.  From 
2  to  4  drops  given  during  meals  in  water, 
the  iodides  being  administered  after 
meals  in  considerable  water,  most  satis- 
factorily serves  the  purpose.    The  car- 


bonate of  ammonia,  the  bromides,  and 
belladonna  have  been  extolled  by  some 
writers,  but  these  agents  are  liable  to  give 
rise  to  unpleasant  symptoms  when  ad- 
ministered during  a  prolonged  period. 
The  bromides  are  especially  objection- 
able. 

The  remedy  need  not  be  discontinued 
when  iodism  is  produced,  in  the  majority 
of  cases.  By  reducing  the  dose  the  un- 
toward effects  may  be  sufficiently  miti- 
gated. When  the  iodides  are  completely 
withdrawn,  they  sometimes  cause  a  re- 
newal of  the  iodism  even  more  severe 
than  the  first  attack. 

Literature  of  '96-'97-'98. 

In  the  treatment  of  iodism  the  use  of 
extract  of  belladonna,  1  to  2  grains, 
daily  recommended  in  order  to  avoid  the 
naso-pharyngeal  symptoms.  Sodium  bi- 
carbonate in  dose  from  90  to  180  grains 
seems  to  benefit  the  general  manifesta- 
tions of  the  poisoning.  Sulphanilic  acid 
in  from  40  to  60  grains  per  diem  will  fix 
the  nitrous  acid,  which,  remaining  in  a 
free  state,  would  decompose  the  iodide. 
In  addition,  a  diet  poor  in  nitrates — as 
milk,  bread,  and  meats — should  be  in- 
sisted upon.  For  the  eruptions,  anti- 
sepsis of  the  skin  is  important;  baths 
and  lotions  of  lime  permanganate  (1  to 
25,000)  are  useful.  The  best  method, 
however,  is  the  preventive.  One  should 
alwajs  commence  with  a  small  dose  (7 
grains),  and  gradually  increase  the 
amount.  Large  quantities  of  milk  and 
even  diuretics  are  prescribed  with  the 
drug.  Haemorrhage  should  be  treated  by 
ergotine,  salivation  by  potassium  chlo- 
rate. (Edema  of  the  glottis  may  neces- 
sitate tracheotomy.  Briquet  (La  Sem. 
Med.,  No.  18,  p.  137,  '96). 

Iodism  is  due  wholly  to  the  elimination 
of  iodine  by  the  various  mucosae  of  the 
body.  The  decomposition  of  the  iodine 
salts  which  precedes  this  elimination  is 
due  to  the  presence  of  nitrites  in  the 
blood.  By  using  naphth ionic  acid  this 
decomposition  is  prevented.  Capitain 
(La  Med.  Mod.,  June  4,  *9S). 


186 


IODINE.    POISONING.  THERAPEUTICS. 


Poisoning  by  Iodine. — A  small  dose 
of  iodine  produces  no  uneasiness  apart 
from  a  metallic  taste  which  is  sometimes 
persistent.  When  large  doses  are  taken, 
the  symptoms  of  iodism  appear;  and  a 
marked  sensation  of  burning  may  be  ex- 
perienced in  the  gastric  region  and  along 
the  oesophagus.  Great  thirst  is  com- 
plained of.  There  is  increased  sexual  ex- 
citement. Nausea,  vomiting,  cramps, 
and  purging  may  be  induced.  There 
may  be  tinnitus,  shooting  pains,  and  in- 
creased flow  of  urine.  When  a  poisonous 
dose  is  taken,  these  symptoms  are  aggra- 
vated; there  is  great  pallor  and  later  on 
cyanosis,  anuria,  and  the  pulse  is  thready, 
and  there  is  marked  prostration.  The 
vomited  matter  is  tinged  yellow  and  the 
urine,  if  any  can  be  obtained,  dark 
brown;  there  is  increasing  nervous  ex- 
citement, spasm,  and  finally  a  comatose 
state. 

The  application  of  iodine  over  large 
surfaces  has  also  induced  toxic  symp- 
toms; its  injection  into  morbid  growths 
likewise. 

The  quantity  of  iodine  capable  of 
causing  toxic  S}^mptoms  varies  greatly. 
While  large  doses  (2  1/2  drachms)  have 
been  taken  without  producing  marked 
effect,  one  scruple  has  induced  violent 
symptoms.  Its  absorption  is  extremely 
rapid;  O'Shaughnessy  found  iodine  in 
the  urine  four  minutes  after  its  injection. 
The  toxic  effects  are  transmissible  to  a 
nursing  infant. 

Case  of  a  woman,  aged  2G,  who  took, 
with  suicidal  intent,  a  half-glass  of  the 
tincture  of  iodine.  She  immediately  be- 
came nauseated,  and  had  a  sense  of  se- 
vere burning  in  the  pharynx  and  oesoph- 
agus. Copious  draughts  of  water  (a 
quart  in  all)  calmed  this  without  induc- 
ing vomiting,  which,  however,  came  on 
in  the  course  of  an  hour,  when  a  dark, 
thick,  very  bitter  fluid  and.  finally,  clear 
blood  were  ejected.  Three  or  four  hours 
after  taking  the  poison  the  patient  suf- 


fered with  abdominal  pains.  In  five 
hours  she  complained  of  dizziness,  and 
in  seven  hours  she  had  an  attack  of 
syncope. 

Treatment  consisted  chiefly  of  milk 
and  starch-water.  The  first  night  was 
sleepless.  The  following  morning  she  had 
moderate  epigastric  tenderness  on  press- 
ure, and  a  sense  of  burning  in  the  stom- 
ach, which  disappeared  in  a  couple  of 
days.  The  urine  was  normal,  and  gave 
no  trace  of  iodine.  This  was  the  case, 
also,  with  the  sweat,  saliva,  and  nasal 
mucus.  Bellot  (La  Med.  Mod.,  Feb.  8, 
'93). 

Two  cases  related  in  which  absorption 
of  the  tincture  of  iodine  applied  to  the 
vaginal  mucous  membrane  occurred.  In 
the  first  case  symptoms  of  intoxication 
appeared  in  six  minutes.  In  the  second 
case  the  application  of  iodine  to  the  cer- 
vical cavity,  in  the  course  of  treatment 
for  an  affection  of  the  genital  organs, 
resulted  in  the  diminution  in  size  of  a 
goitre.  Repin  (Revue  Med.  de  la  Suisse 
Rom.,  July  20,  '93). 

Treatment  of  Iodine  Poisoning. — The 
usual  antidote  employed  is  starch,  but 
white  of  egg  or  milk  are,  according  to 
Trousseau,  indicated  by  the  greater  affin- 
ity of  proteid  substances  for  iodine.  The 
stomach  should  be  emptied  soon  after  the 
use  of  either  of  these  substances  to  reduce 
the  intensity  of  the  subsequent  effects. 
The  other  symptoms  present  should  be 
treated  on  general  principles,  the  tend- 
ency to  collapse  being  combated  by  ap- 
propriate stimulants  injected  per  rectum 
and  hypodermically. 

Therapeutics. — Iodine  and  it >  prepara- 
tions are  extensively  used,  but  in  syphilis, 

J  one  of  its  salts,  the  iodide  of  potassium, 
may  be  said  to  be  invaluable,  especially 
in  the  tertiary  form  and  all  the  mani- 
festations of  the  disease  in  which  the 
various  organs  are  involved.  As  the  in- 
dications are  thoroughly  reviewed  under 
each  special  heading,  including  Syphi- 

i  lis,  more  than  a  reference  here  would  be 


IODINE.  THERAPEUTICS. 


187 


superfluous.  The  best  plan  is  to  adminis- 
ter in  increasing  doses,  beginning  with  I 
10  grains,  three  times  a  day,  gradually 
increasing  the  dose  by  1  grain  a  day  until 
the  limit  of  toleration  is  reached.  Many 
patients  reach  1  drachm  and  beyond,  : 
especially  if  plenty  of  pure  spring-water 
is  drunk  simultaneously. 

The  indications  for  the  administration 
of  iodine  are  clearly  given  by  Comby. 
Iodine  is  considered  a  specific  in  heredi- 
tary syphilis  and  in  the  tardy  symptoms 
of  acquired  syphilis.  In  the  initial  and 
secondary  stages  mercury  alone  is  suffi- 
cient; in  the  tertiary  stage  iodide  of  ! 
potash  is  indicated.  An  exception  is 
made  in  the  hereditary  syphilis  of  the 
newborn,  in  whom  the  exhibition  of 
iodide  of  potash  should  be  begun  early. 
Not  only  should  positively  syphilitic 
children  receive  iodine,  but  all  who  have 
suspicious  symptoms,  as  coryza,  exostoses,  i 
etc.,  or  a  cachexia  which  appears  without  ! 
apparent  cause,  or  when  the  child  is 
prematurely  born,  or  the  mother  has  had  I 
frequent  abortions.  In  convulsions, 
pseudoparalysis,  meningeal  symptoms,  I 
etc.,  it  is  also  indicated.  The  adminis- 
tration of  iodine  in  children  with  gummy 
tumors,  disease  of  bone,  perforation  of 
the  soft  palate  and  hemoglobinuria  is, 
of  course,  clearly  indicated.  Finally,  in 
all  parasyphilitic  symptoms  (Fournier), 
as  hydrocephalus,  cerebral  tumors,  par- 
tial epilepsy,  etc.,  iodine  is  valuable. 

In  metallic  poisoning  iodide  of  potas- 
sium, by  forming  soluble  salts  with  mer- 
cury and  lead,  causes  these  metals  to  be 
eliminated  from  the  system.  In  painter's 
colic,  therefore,  wrist-drop,  and  other  I 
manifestations  of  lead  poisoning  and  mer- 
curial poisoning  it  serves  an  inestimable 
purpose.  At  times,  however,  either  of 
these  metals  may  lie  practically  dormant 
in  the  tissues,  and  suddenly  find  them- 
selves brought  into  activity  by  the  iodide 


of  potassium,  signs  of  severe  poisoning 
following.  "When,  therefore,  there  is 
good  reason  for  the  belief  that  consider- 
able lead  or  mercury  is  lying  in  the 
system,  the  treatment  should  be  started 
with  small  doses;  this  can  then  be  very 
gradually  increased — considerable  water 
should  be  drunk  to  assist  the  process  of 
elimination  and  reduce,  by  lowering  as 
much  as  possible  the  specific  gravity  of 
the  urine,  lesions  of  the  kidney. 

It  is  generally  accepted  that  sodium 
iodide  is  preferable  to  potassium  iodide 
in  all  diseases  of  the  respiratory  tract  and 
for  certain  rheumatic  pains.  The  potas- 
sium salt  is  badly  tolerated  in  many  in- 
stances of  hepatic  disease,  but  is  unde- 
niably good  in  these  cases.  Where  the 
patients  do  not  tolerate  iodide  of  potas- 
sium well,  the  employment  of  iodide  of 
sodium  first  prepares  them  for  the  potas- 
sium salt. 

Diseases  of  the  Bespiratory 
Tract. —  In  phthisis  iodine  has  been 
recommended,  but  it  is  doubtful  whether 
it  is  productive  of  much  benefit.  Inhala- 
tions of  its  vapor  have  been  extolled  as 
an  excellent  stimulant  to  the  mucous 
membrane.  The  danger  of  haemoptysis 
is  always  present,  however,  and  is  likely 
to  be  increased  by  stimulation  of  this 
kind. 

In  the  early  stages  the  local  applica- 
tion of  iodine  over  the  threatened  or  dis- 
eased area  is  of  great  service.  The  front 
and  back  of  the  chest  may  be  painted  on 
alternate  days,  thus  keeping  the  patient 
under  the  influence  of  the  remedy.  The 
application  of  cotton-wadding  over  the 
painted  areas  tends  to  increase  the  effi- 
cacy of  the  treatment. 

In  pleuritic  effusions,  pleurod}rnia, 
circumscribed  pneumonia  and  bronchitis, 
the  same  proceeding  is  sometimes  re- 
markably effective,  especially  if  the 
region  is  kept  warm. 


188 


IODINE.  THERAPEUTICS. 


Iodide  of  potassium  and  sodium  can  be 
employed  with  advantage  in  the  chronic 
forms  of  croupous  pneumonia  and  the 
pneumonia  following  or  complicating  in- 
fluenza, beginning  on  or  about  the 
twelfth  day  of  the  disease.  In  doses  of 
23  to  30  grains  per  day  for  adults,  and 
proportionately  smaller  ones  in  children. 
G.  Zielinski  (Univ.  Med.  Jour.,  July, 
'93). 

Iodine  diluted  to  1/10  or  Vs  is  a  very 
useful  application  in  whooping-cough, 
applied  on  cotton  to  the  glottis.  Labbe 
(Phila.  Med.  Times,  Feb.  1.  '88). 

Iodide  of  potassium  is  particularly 
valuable  in  asthma,  especially  when  com- 
bined with  belladonna.  An  efficacious 
preparation  is  the  following: — 

1>  Iodide  of  potassium,  2  drachms. 
Water,  enough  to  dissolve  the  io- 
dide, 
Then  add:— 

Tincture  of  belladonna,  2  drachms. 
Syrup  of  orange-peel,  enough  to 
make  3  ounces. 

Iodide  of  potassium  employed  not  only 
in  asthmatic  dyspnoea,  but  in  that  of 
cardiac  origin.  G.  See  (Jour,  de  Med.  et 
de  Chir.,  July,  '88). 

It  is  an  error  to  suppose  that  potas- 
sium salts  are  especially  poisonous  to 
the  heart.  The  sodium  salt  has  no  ad- 
vantage, and  is  just  as  liable  to  produce 
iodism.  The  iodides  are  useful  (1)  for 
dyspnoea  of  a  secondary  nature,  (2)  in 
troubles  of  intrapulmonary  circulation. 
(3)  for  reducing  the  volume  of  aneu- 
risms, (4)  for  reducing  the  size  of  a  tumor 
and  thus  relieving  the  symptoms  of  com- 
pression. G.  See  (Le  Bull.  Med.,  Aug. 
15,  '88). 

In  the  peribronchial  enlargements  so 
frequently  encountered  in  scrofulous 
children  the  exhibition  of  iodine  is  often 
attended  by  considerable  benefit,  espe- 
cially when  combined  with  local  applica- 
tions. The  syrup  of  the  iodide  of  iron, 
given  in  5-drop  doses,  three  times  daily 
and  gradually  increased,  is  especially 
valuable  in  this  connection. 


In  naso-pharyngeal  affections  weak  so- 
lutions of  iodine  in  glycerin  are  of  great 
value,  when  gently  applied  night  and 
morning  with  a  camel's-hair  pencil  or  a 
pledget  of  cotton.  Lacrymal  disorders 
are  also  benefited  by  the  same  applica- 
tions; when  iodine  is  simultaneously 
painted  over  the  thyroid  cartilage,  the 
effect  is  enhanced. 

Good  results  obtained  in  the  treatment 
of  atrophic  naso-pharyngeal  affections 
from  the  application  of  pure  tincture  of 
iodine.  After  cleansing  and  using  a  5- 
per-cent.  solution  of  cocaine  the  iodine 
is  lightly  applied  with  a  small  brush  of 
absorbent  cotton.  The  applications  are 
made  at  first  every  second  day;  later 
on,  once  a  week.  Hunter  Mackenzie 
(Brit.  Med.  Jour.,  Apr.  27,  '95). 

Sckofulosis.  —  In  scrofulous  affec- 
tions— so  called — iodine  fulfills  a  useful 
purpose.  Lugol,  who  did  so  much  to 
show  the  merits  of  iodine  in  this  class  of 
cases,  is  said  to  have  obtained  a  large  pro- 
portion of  recoveries  by  means  of  the 
solution  bearing  his  name  as  far  back  as 
1828.  Bazin  recommended  it  especially 
in  early  manifestations  before  the  cervi- 
cal glands  were  too  greatly  enlarged,  and 
when  ulceration  was  not  near  at  hand. 
All  glandular  enlargements,  joint-en- 
largements, and  osseous  disorders  are 
beneficially  influenced  by  iodine  used  in- 
ternally and  externally  simultaneously. 

Rheumatism. — In  this  disease  iodide 
of  potassium  is  a  valuable  remedy,  but 
only  in  the  subacute  or  muscular  form, 
i.e.,  when  the  acute  or  inflammatory 
symptoms  have  passed.  To  give  it  dur- 
ing the  inflammatory  stage  is  worse  than 
useless.  It  may  be  used,  however,  in 
rheumatic  pains  devoid  of  inflammatory 
manifestations,  lumbago,  sciatica.  Its 
efficacy  is  vastly  increased  in  all  forms  of 
rheumatism  by  the  addition  of  colchi- 
cum.  The  following  formula  may  be 
recommended : — 


IODINE.  THERAPEUTICS. 


189 


5  Iodide  of  potassium,  2  drachms. 

Enough  water  to  dissolve  this. 
Then  add: — 

Tinct.     of     colchicum  -  root,  3 

drachms. 
Syrup  of  orange-peel,  enough  to 
make  3  ounces. 
M.    Sig. :  One  teaspoonf ul  to  be  taken 
every  three  hours. 

The  local  application  of  iodine  over 
the  painful  area,  this  being  then  covered 
with  cotton  wadding,  greatly  hastens  the 
curative  process. 

Goitre. — As  shown  in  the  section  on 
Goitre  (volume  iii),  iodine  is  of  great 
value  in  this  disease,  and  is  now  second 
only  to  thyroid  extract  when  utilized  in 
appropriate  cases,  namely:  those  suffer- 
ing from  the  true  hypertrophic  variety. 
When  the  goitre  is  cystic,  or  the  gland  is 
but  the  seat  of  a  neoplasm.,  benign  or 
malignant,  iodine  is  obviously  useless. 

Iodine  has  also  been  used  with  ad- 
vantage in  exophthalmic  goitre. 

Use  of  iodine  by  cataphoresis  in  an  old 
case  of  goitre  where  subjective  symp- 
toms were  very  severe, — 10  to  15  drops 
on  cotton  in  cup-shaped  electrode  daily 
for  three  weeks, — intermission  of  three 
weeks — treatment  persisted  in  for  three 
weeks  more. 

The  gland  was  reduced  to  about  one- 
fifth  the  size  it  was  when  the  treatment 
was  begun,  and,  in  spite  of  all  further 
use  of  the  remedy,  remained  stationary; 
but  all  of  the  subjective  symptoms  were 
gone,  and  the  woman  left  in  excellent 
health.  Two  other  cases  of  chronic 
goitre  have  been  treated  in  the  same 
way,  and  with  the  same  results.  In  4 
cases  of  recent  hypertrophy  of  the  thy- 
roid gland  in  young  women,  the  enlarge- 
ment rapidly  disappeared  under  the  use 
of  this  measure.  McGuire  (Virginia 
Med.  Month.  Review,  Aug.,  '91). 

Case  of  simple  goitre  in  which,  after 
failure  of  the  iodine  treatment,  the  use 
of  glycerol  extract  of  the  thyroid  gland 
resulted  in  complete  cure.  Sabrazes 
(Berl.  klin.  Woch.,  Feb.  3,  '90). 


Skin  Disorders. — Tincture  of  iodine 
applied  over  inflamed  surfaces  sometimes 
overcomes  inflammatory  disorders  of  the 
skin.  Erysipelas,  thus  treated  early,  may 
be  aborted;  late  in  the  disease,  how- 
ever, the  results  are  not  so  satisfactory. 
It  should  be  applied  once  daily.  The 
pitting  of  small-pox  may  be  greatly  coun- 
teracted by  touching  each  pustule  with 
iodine.  In  acne,  psoriasis,  pityriasis,  and 
ringworm  it  is  also  used  advantageously. 
In  actinomycosis  (q.  v.)  iodide  of  potas- 
sium is  the  most  efficacious  remedy. 

The  writer  has  cured,  with  iodide  of 
potassium,  two  cases  of  actinomycosis 
in  man,  one  a  tumor  occupying  all  the 
submaxillary  region,  and  on  the  region 
of  the  caecum,  considered  at  first  as  a 
perityphlitis.  The  doses  were  7  3A  to  31 
grains  per  day  in  the  first  case,  and  15  V2 
grains  per  day  in  the  second  case,  for 
sixteen  days.  V.  Herson  (Wiener  med. 
Presse,  Jan.  8,  '93). 

Surgical  Uses.  —  Iodine  possesses 
marked  antiseptic  properties,  as  first 
shown  by  Liebig.  Fibrin  immersed  in 
iodized  water  does  not  undergo  putre- 
faction. Pus  treated  with  iodine  does 
not  have  the  foetid  odor  after  several 
days  which  can,  without  the  iodine,  be 
detected  in  a  few  hours  when  exposed  to 
the  air.  The  addition  of  a  few  drops  of 
iodine  to  foetid  pus  causes  the  odor  to  dis- 
appear. 

Irrigations  of  iodine-water,  of  the 
strength  of  1  to  10,000,  used  for  the 
treatment  of  wounds,  this  to  be  fol- 
lowed by  the  application  of  either  pure 
aristol  or  a  mixture  of  1  part  of  aristol 
to  4  of  boric  acid.  Under  such  treatment 
luxuriant  and  profusely-bleeding  gran- 
ulations quickly  returned  to  their 
normal  appearance.  Tikon  von  Popoff 
(Brit.  Med.  Jour.,  Sup.,  Aug.  1,  '91). 

A  litre  of  spring-water  may  be  steril- 
ized in  a  few  minutes  by  4  drops  of 
tincture  of  iodine;  even  less  will  cause 
the  annihilation  of  pathogenic  microbes. 
Meillere  (La  Tribune  Med.,  Dec.  26,  '94). 


190 


IODINE.  THERAPEUTICS. 


Iodine  trichloride  is  recommended  for 
the  treatment  of  tuberculous  and  sup- 
purative processes.  It  may  also  be  em- 
ployed for  cancerous  surfaces  and  vene- 
real sores,  in  5-  to  20-per-cent.  solution 
in  equal  parts  of  water,  ether,  and  glyc- 
erin. Solutions  stronger  than  5  per  cent, 
cause  smarting  in  ordinary  wounds.  The 
author  states  that  gauze  sterilized  by 
boiling  and  dried,  after  being  immersed 
in  a  1-  to  10-per-cent,  aqueous  solution, 
retains  iodine  trichloride  for  an  indefi- 
nite time.  Belfield  (Med.  Record,  July 
16,  '92). 

Good  results  obtained  in  the  treatment 
of  two  cases  of  vesical  tuberculosis  and 
one  of  tubercular  epididymitis  by  a  5- 
per-cent.  aqueous  solution  of  iodine  tri- 
chloride. Belfield  (Jour.  Cut.  and 
Genito-Urin.  Dis.,  Aug.,  '92). 

Excellent  results  obtained  in  the  treat- 
ment of  tubercular  joint-disease,  tuber- 
cular adenitis,  and  even  in  pulmonary 
tuberculosis,  by  the  hypodermic  injec- 
tion of  iodine  in  the  following  combina- 
tion: from  1  to  5  parts  of  iodine,  10 
parts  of  the  potassium  iodide,  and  100 
parts  of  distilled  water;  1  cubic  centi- 
metre of  this  liquid  being  injected  each 
day,  using  first  the  1-per-cent.  solution 
and  gradually  advancing  to  the  5-per- 
cent, solution.  The  injections  of  iodine 
should  be  continued  for  at  least  six 
months.  Durante  (Med.  Week,  '94,  ii, 
p.  274). 

Iodine  injected  into  sinuses  greatly 
aids  in  their  closure.  De  Forest  Willard 
(Annals  of  Surgery,  Dec.,  '96). 

External  Application. — The  tinct- 
ure of  iodine  is  extensively  used  as  a 
counter-irritant.  As  such  it  ma)7  be  said 
to  have  become  a  household  remedy,  and 
to  be  more  or  less  beneficial  in  almost  all 
ailments  characterized  by  pain,  except 
when  abrasions  are  present.  When  ap- 
plied over  the  skin,  the  latter  becomes 
yellow  and  future  applications  gradually 
cause  it  to  become  brown.  Burning  and 
itching  are  then  experienced;  the  appli- 
cations had  better  be  stopped  until  the 
distressing  symptoms  disappear.  As  al- 
ready stated,  poisoning  can  occur  when 


too  great  an  area  is  covered.  As  a  rule, 
the  surface  covered  should  not  exceed 
that  represented  by  the  two  hands. 
When  applied  over  the  chest,  its  effects 
may  be  sustained  by  painting  the  front  of 
the  thorax  one  day  and  the  back  the  next. 
A  piece  of  cotton  wadding  placed  over 
the  surfaces  thus  treated  enhances  the 
efficacy  of  the  iodine.  In  ophthalmology 
it  is  frequently  employed  in  the  treat- 
ment of  trachoma. 

The  following  method  of  employing 
iodine  topically  is  of  service.  A  piece  of 
gutta-percha  tissue  is  taken  and  given 
three  or  more  coatings  of  tincture  of 
iodine;  it  is  then  dried  and  applied  in 
the  selected  locality,  with  the  iodine 
coating  turned  toward  the  skin,  and 
secured  with  a  roller  bandage.  In  this 
way  the  good  results  of  the  topical  ap- 
plication of  iodine  may  be  secured  with- 
out smarting.  M.  Iversen  (Med.  Xews. 
Apr.  20,  '95). 

Eymonnet  has  prepared  a  paper  moist- 
ened with  solution  of  potassium  iodide 
and  dried,  and  another  paper  prepared 
with  potassium  iodide  and  tartaric  acid, 
moistened  and  dried.  If  these  papers  be 
kept  separate  and  dry  they  will  keep  in- 
definitely. If  a  rubefacient  be  required, 
the  papers  are  moistened  and  brought 
in  contact  with  the  skin.  Iodine  is  liber- 
ated and  causes  a  reddening  of  the  skin, 
followed  by  desquamation.  R.  Lepine 
(La  Semaine  Med.,  Jan.  30,  '89). 

Literature  of  '96-'97-9&. 

Iodine  applied  by  painting  is  absorbed 
by  the  skin.  This  absorption,  very  small 
when  the  painted  part  is  exposed  to  the 
air,  becomes  much  more  active  when  it 
is  hermetically  covered.  The  superficial 
alteration  of  the  epidermis  produced  by 
I  lie  tincture  of  iodine,  provided  it  does 
not  go  on  to  destruction  of  the  corneous 
layer,  appears  to  be  an  obstacle  rather 
than  an  aid  to  absorption.  Under  the 
most  favorable  conditions  the  absorption 
is  too  irregular  to  make  the  painting  of 
iodine  useful  in  general  iodine  medica- 
tion. Iodoform  and  ethyl-iodide  are  ab- 
sorbed by  the  healthy  skin,  the  latter 
in   sufficient  quantity  to  be  useful,  if 


IODINE.  THERAPEUTICS. 


191 


needful,  for  a  general  iodine  treatment.  | 
Linossier  and  Lannois    (Bull.  Gen.  de 
Ther.,  9e  liv.,  p.  385,  '97). 

Seventy-eight  cases  out  of  100  cured  j 
with  nascent  iodine  generated  by  admin- 
istering potassium  iodide  internally,  and, 
when  the  iodine  begins  to  be  eliminated 
in  the  lacrymal  secretions,  painting  the 
upturned  lid  with  oxygenated  water.  R. 
Roselli  (Semaine  Med.,  July  20,  '98). 

Hypodekmic  Injection.  —  Hypoder- 
mic injections  of  iodine  are  extremely 
painful  and  give  rise  to  considerable  irri- 
tation. Iodide  of  potassium  can  be  used 
hypodermically,  however,  and  is  not  pro- 
ductive of  so  much  pain  if  lukewarm 
water  be  employed. 

Rectal  Injections. — Rectal  injec- 
tions of  iodine  solutions  have  been  used 
in  colitis  or  in  diseases  in  which  this  con- 
dition is  the  most  prominent  factor,  dys- 
entery and  chronic  diarrhoea,  the  ulcer- 
ative processes  present  being  favorably 
influenced.  One  drachm  of  Lugol's  solu- 
tion in  1  pint  of  lukewarm  water  may  be 
used  after  carefully  cleansing  the  bowel 
by  means  of  an  enema.  If  pain  is  caused 
by  the  mixture  employed,  1  drachm  of 
iodide  of  potassium  may  be  substituted 
for  LugoPs  solution,  or  a  small  quantity 
of  extract  of  opium  may  be  added.  Two 
pints  should  be  injected  night  and  morn- 
ing, the  strength  of  the  solution  being 
increased  if  need  be. 

Study  of  the  absorption  of  iodide  of 
potassium  from  the  rectum  of  healthy 
and  sick  persons;  conclusions:  1.  In 
eight  healthy  persons  iodine  could  be 
discovered  in  the  saliva  in  from  five  to 
nine  minutes,  the  average  being  seven 
minutes.  2.  In  five  patients  with  lesions 
about  the  rectum  or  in  its  neighborhood 
(Cancer  of  the  rectum,  parametritis, 
retro-uterine  hematocele,  etc.)  the  ab- 
sorption was  retarded,  the  time  varying 
between  nine  and  fifteen  minutes.  3.  The 
same  retardation  occurred  in  seven  pa- 
tients with  remote  affections  (acute 
nephritis,  malignant  disease  of  the  stom- 
ach, cardiac  organic  disease,  etc.),  the 


time  averaging  about  fourteen  minutes. 
4.  When  in  the  form  of  solution  the 
iodide  was  absorbed  by  the  rectal  mucous 
membrane  more  rapidly  than  when  in 
that  of  suppository,  the  difference 
amounting  to  several  minutes.  The  io- 
dide was  introduced  into  the  rectum 
either  in  aqueous  solution— 2  1/2  drachms 
to  1  V2  ounces — or  in  suppositories  con- 
taining the  same  amount  of  the  salt. 
Raczkiewicz  (Pamietnik  Towarzystiva 
Lekarskiego  Warszawskiego,  '92). 

The  absorption  of  potassium  iodide, 
when  introduced  into  the  rectum,  is  as 
rapid  as  when  given  by  the  stomach.  If 
it  be  desired  to  obtain  a  still  more  rapid 
absorption,  the  solution  may  be  heated 
from  95°  to  98.6°  F.  The  time  during 
which  elimination  goes  on  is  practic- 
ally the  same  by  either  method  of 
administration.  With  the  weak  solu- 
tions ordinarily  given,  elimination  is 
complete  in  from  twenty-four  to  thirty 
hours.  Concentrated  solutions  are  ex- 
creted more  slowly, — that  is,  in  from 
thirty-eight  to  forty  hours.  Calantoni 
(Riforma  Medica,  Apr.  26,  '92). 

Iodide  of  potassium  detected  in  the 
saliva  in  about  fifteen  minutes  after  its 
administration  by  the  mouth,  and  in  ten 
minutes  after  its  introduction  through 
the  rectum.  Lemanski  and  Main  (Le 
Bull.  Med.,  Jan.  29,  '93). 

The  iodide  of  potassium,  ingested  by 
the  rectum,  is  eliminated  by  the  stom- 
ach, this  elimination  beginning  from 
one-fourth  to  one-half  hour  before  that 
occurring  by  the  kidneys.  P.  Kandidoff 
(Wratsch,  Apr.,  '93). 

Parenchymatous  Injections. — 
These  are  still  considerably  employed  in 
hydrocele  after  evacuation  of  the  fluid. 
The  iodine  is  supposed  to  excite  local  in- 
flammation and  obliteration  of  the  cavity. 
Hydatid  cysts  can  also  be  treated  ad- 
vantageously in  the  same  manner,  a  few 
drops  of  the  tincture  injected  in  the 
cavity  being  sufficient.  In  empyema  the 
removal  of  the  liquid  by  aspiration  and 
the  injection  of  a  weak  solution  (6  grains 
of  iodine  and  iodide  of  potassium  to  the 
pint,  according  to  H.  C.  Wood)  may  be 


192 


IODINE  AND  DERIVATIVES.  IODOFORM. 


used  to  wash  out  the  pleura  every  day. 
If  no  untoward  symptoms  are  observed, 
the  strength  of  the  solution  can  be  in- 
creased. This  solution  may  be  used  in 
washing  out  abscesses  of  all  kinds.  In 
cystic  goitre  parenchymatous  injections 
have  also  proved  curative  (see  Goitke, 
volume  iii). 
Iodoform. 

This  precious  agent  was  introduced 
by  Serullas  in  1822.  but  was  first  used 
in  practice  by  Bouchardat  in  1836, 
then  by  Glover  in  1837.  Khigini,  in 
1853,  brought  to  light  its  great  value  as 
an  antiseptic  and  disinfectant.  Iodoform 
is  obtained  by  the  action  of  various  alco- 
hols or  proteid  compounds  upon  iodine 
(CHI3),  and  occurs  as  small  yellow  crys- 
tals, having  a  penetrating  persistent 
saffron-like  odor,  which  adheres  to  every 
object  with  which  the  drug  comes  in  con- 
tact. This  peculiar  odor  is  one  of  the 
greatest  drawbacks  of  iodoform  and  has 
greatly  contributed  to  limit  its  employ- 
ment. Patients  are  rendered  obnoxious 
to  their  friends,  while  the  physician  can 
with  difficulty  rid  himself  of  the  offen- 
siveness  incurred  by  its  use  as  a  remedy. 

Among  the  methods  recommended  to 
deodorize  iodoform  without  altering  its 
therapeutic  properties  are  the  follow- 
ing:— 

Oil  of  sassafras,  4  drops  to  the  ounce 
of  iodoform  (Dodsley). 

A  few  drops  of  any  of  the  aromatic 
oils:  almonds,  musk,  tar,  etc.  (Charteris). 

Oil  of  evodia  fraxinifolia,  2  drops  to 
the  ounce  of  iodoform  (Ilelbing). 

One  part  of  menthol  and  1  part  of  oil 
of  lavender  to  20  parts  of  iodoform  (Can- 
trelli). 

One  part  of  menthol  to  20  parts  of 
iodoform  (Caubrelle). 

One  or  2  parts  of  creolin  to  100  of  iodo- 
form (von  Jaksch). 

To  remove  the  odor  from  the  hands  or 


the  clothes  of  the  surgeon  the  readiest 
means  is  to  use  ether  or  chloroform 
(Washburn). 

Literature  of  '96-'97-'98. 

Washing  the  hands  with  orange-flower 
water  is  sufficient  to  dispel  the  odor  of 
iodoform  after  handling  that  substance. 
Constan  (Lyon  Med.,  Nov.  28,  '97). 

Preparations  and  Dose. — In  the  treat- 
ment of  wounds  the  powder  is  generally 
used,  and  with  dangerous  freedom  by 
many  surgeons.  Thirty  grains  should  be 
the  limit  for  any  single  application  of  the 
drug,  and  a  smaller  quantity  should  be 
employed  as  a  rule. 

Internally,  the  powder  may  be  given 
in  doses  ranging  from  1  to  5  grains  to 
adults. 

Iodoform  is  insoluble  in  water,  but 
soluble  in  ether,  alcohol,  and  the  fixed 
volatile  oils.  Ethylic  alcohol  saturated 
with  camphor  can  dissolve  eight  times  as 
much  iodoform  as  pure  alcohol. 

Solutions  of  iodoform  should  be  kept 
in  red  or  green  glass  bottles,  in  order  to 
prevent  the  liberation  of  iodine  from 
them  under  the  influence  of  light. 

When  glycerin  or  oil  is  used  5-  or  10- 
per-cent.  solution  is  generally  preferred. 
The  former  is  preferred  for  the  treatment 
of  serous  cavities. 

The  iodoform-oil  is  of  more  value  to 
the  average  physician  than  the  iodoform- 
glycerin  mixture,  because  of  the  ease 
with  which  it  can  be  prepared  and  ster- 
ilized. The  sterilization  of  the  latter, 
however,  may  be  done  as  follows:  The 
glycerin  should  be  heated  by  itself,  and 
after  it  has  been  allowed  to  cool  the 
proper  amount  of  iodoform  should  be 
added.  The  advantages  of  this  method 
are  that  the  iodoform  is  not  decomposed 
by  the  boat.  Stubenrauch  (Oentralb.  f. 
Chir.,  Dec.  10.  '92). 

At  a  temperature  of  t>4..~)0  F.  (»7  parts 
of  alcohol  at  95  per  cent,  are  required  to 
dissolve  1  part  of  iodoform,  while  at  the 


IODINE  AND  DERIVATIVES.    UNTOWARD  EFFECTS  OF  IODOFORM. 


193 


boiling-point  9  parts  at  95  per  cent,  are 
sufficient  to  dissolve  1  part;  of  ether, 
5.6  parts  are  required  to  dissolve  1  part 
of  iodoform.  G.  Vulpius  (Pharm.  Cen- 
tralh.  f.  Deutschland,  '93). 

Saturated  solutions  of  iodoform  in 
ether  become,  as  the  point  of  saturation 
is  reached,  very  unstable,  and  under  the 
influence  of  the  slightest  causes  they  are 
decomposed  suddenly,  a  reddish  color  re- 
sembling that  of  tincture  of  iodine  re- 
sulting. The  decomposition  is  rendered 
less  rapid  if  the  solutions  are  less  con- 
centrated. In  saturated  ethereal  solu- 
tions it  may  be  retarded  by  the  addition 
of  alcohol  and  by  keeping  them  protected 
from  sunlight. 

The  ointment  of  iodoform  (U.  S.  P.) 
contains  10  per  cent,  of  the  drug. 

Physiological  Action. — Iodoform  con- 
taining about  29  parts  of  pure  iodine  in 
30,  the  carbon  and  hydrogen  with  which 
it  is  associated  render  the  iodine  non- 
irritant,  either  when  taken  by  the  mouth 
or  applied  topically.  It  is  markedly  anaes- 
thetic when  locally  applied,  owing  to  a 
benumbing  influence  upon  the  peripheral 
nerves.  Defecation  may  follow  the  use 
of  iodoform  suppositories,  and  not  be  felt 
by  the  patient. 

Iodoform  tends  to  decrease  the  energy 
of  cardiac  contractions  and  reduces  the 
number  of  pulsations.  When  toxic  doses 
are  administered  the  contractions  become 
gradually  weaker  and  the  heart  ceases  its 
work  in  diastole.  The  action  begins 
upon  the  nerve-trunks,  then  extends  to 
the  muscles.  There  is  alteration  of  the 
blood-corpuscles,  according  to  Floucaud. 

Rummo  has  shown  that  the  elimina- 
tion of  iodoform  is  extremely  slow, 
though  it  begins  soon  after  its  ingestion. 
It  leaves  the  organism  by  all  the  secre- 
tions and  iodine  may  still  be  found  in 
the  urine  three  days  after  the  iodoform 
is  employed. 


In  dogs  poisoned  by  iodoform  Kori- 
andere  found  inflammation  of  the  glom- 
eruli of  the  kidney  and  fatty  infiltra- 
tion of  the  liver,  principally  around  the 
periphery  of  the  lobules.  In  chronic 
cases  he  found,  besides  these  changes,  ex- 
treme emaciation,  general  anaemia,  puru- 
lent bronchitis,  rhinitis,  conjunctivitis, 
and  accumulation  of  pigment  in  the  Mal- 
pighian  bodies. 

Untoward  Effects  of  Iodoform. — Re- 
cently Hubener  has  shown  that  no  essen- 
tial difference  in  the  toxic  effects  of 
finely  powdered  or  coarse  crystals  of 
iodoform  can  be  established  by  experi- 
mental research.  Still,  powdered  iodo- 
form is  more  quickly  absorbed  and  dif- 
fused by  the  lymph-channels  than  the 
coarser  form. 

Experiments  in  animals  have  shown 
that,  when  used  in  the  peritoneal  cavity, 
iodoform  has  a  distinct  tendency  to  pro- 
duce an  inflammatory  process,  resulting 
in  an  excessive  formation  of  adhesions. 
Consequently  its  use  under  such  condi- 
tions" should  be  restricted,  and  the  sterile 
gauze  employed  whenever  feasible. 

Crystals  of  iodoform  have  been  found 
to  a  large  extent  to  become  converted  by 
the  action  of  the  tissues  into  minute 
vesicle-like  granules.  Prior  to  its  ulti- 
mate breaking  up  into  its  chemical  com- 
ponents, it  undergoes  a  change  into  com- 
plicated iodine  compounds,  whose  exact 
nature  as  yet  remain  unknown. 

Many  of  the  untoward  results  observed 
during  the  use  of  iodoform  are  due  to 
impurities.  In  order  to  test  the  purity 
of  iodoform,  a  practical  plan  is  to  shake 
a  portion  up  with  distilled  water,  filter, 
and  treat  the  liquid  with  alcoholized  solu- 
tion of  nitrate  of  silver.  If  in  twenty- 
four  hours  no  precipitate  occurs,  or  only 
a  slight  grayish  cloudiness,  the  iodoform 
may  be  regarded  as  pure. 

When  iodoform  is  employed,  the  use  of 


4—13 


194        IODINE  AND  DERIVATIVES.    UNTOWARD  EFFECTS  OF  IODOFORM. 


mercurials  should  be  avoided.  Its  use 
along  with  carbolic  acid  is  also  fraught 
with  danger. 

Literature  of  '96-'97-'98. 

Mercurous  iodide  poisoning  resulting 
from  the  use  of  iodoform  as  a  surgical 
dressing  and  calomel  internally.  Simp- 
son (Amer.  Jour,  of  Obstetrics,  Apr.,  '98). 

The  local  symptoms  due  to  iodoform 
are  generally  insignificant  erythematous 
erosions,  erysipelas,  or  simulated  phleg- 
mon, especially  affecting  the  finer  por- 
tions of  the  skin,  as  the  face,  eyelids, 
scrotum,  etc.  The  conjunctiva,  however, 
appears  to  be  tolerant  of  the  drug,  and 
the  eruptions  are  rarely  observed  in  chil- 
dren. The  local  lesions  are  almost  always 
due  to  the  use  of  the  powder  and  gauze. 
General  symptoms  may  occur  without 
any  preceding  local  symptoms,  the  point 
of  entrance  being  the  stomach,  lungs,  or 
skin.  Injections  of  iodoform-ether  are 
rarely  followed  by  accidents,  though  cer- 
tain wounds  predispose  to  such,  espe- 
cially those  involving  fatty  tissue. 

The  clinical  signs  are  a  sudden  rise  of 
temperature  (102.2°  to  104°  F.)  and  the 
appearance,  on  the  same  day  or  the  fol- 
lowing day,  of  an  eruption,  often  of  the 
scarlatiniform  or  erythematous  type.  In- 
ternal symptoms  may  exist  at  the  same 
time  or  alone,  such  as  dislike  for  food, 
burning  sensation  in  the  epigastrium, 
vomiting,  and  nausea.  All  these  phe- 
nomena may  be  sufficiently  severe  to 
cause  death.  (Cheron.) 

Literature  of  '96-'97-'98. 

What  may  be  termed  "surgical  iodo- 
formism"  is  sometimes  met  with.  After 
a  longer  or  shorter  period  of  complete 
toleration  the  wound,  while  secreting 
no  pus,  is  surrounded  by  an  inflam- 
matory area  with  development  at  its 
circumference  of  inflammatory  vesicles 
(iodoformic  herpes).  Petechia?  appear 
near  the  wound   or  at   a   distance  in 


patches  or  groups.  The  wound  stagnates 
and  inflames,  but  does  not  heal.  A  gen- 
eralized pruritus  along  the  collateral 
nerves  of  the  fingers  follows,  succeeded  by 
diffuse  phlyctenular.  Areolar  or  pseudo- 
erysipelatous  lymphangitis  appears  in 
the  affected  limb.  If  the  use  of  iodo- 
form is  persisted  in  lymphangitis  pro- 
gresses, the  tongue  becomes  coated,  and 
the  patient  is  agitated  and  sleepless.  A 
phlegmonous  condition  with  general 
symptoms  develops,  and  necrosis  may 
threaten  the  patient  with  loss  of  limb  or 
life.    Tussau  (Semaine  Med.,  Nov.,  '96). 

Case  of  a  woman  in  good  health,  who 
died  of  iodoform  poisoning.  On  the  left 
leg  was  a  small  varicose  ulcer  which  had 
been  dressed  with  iodoform  powder. 
After  this  treatment  tumefaction  set  in 
and  the  leg  became  red  and  painful,  and 
at  the  end  of  eight  days  there  was  a 
generalized  eruption.  Editorial  (Revue 
M6d.  de  la  Suisse  Rom.,  p.  431,  '96). 

Case  of  a  woman  who  sustained  burns 
of  the  thighs  and  abdomen  to  which 
iodoform  dressings  were  applied.  After 
three  weeks  without  other  signs  of  gen- 
eral poisoning  a  progressive  amblyopia 
appeared,  accompanied  by  atrophy  of  the 
temporal  half  of  both  disks.  Terson 
(Societe  de  Biol.;  Annales  d'Ocul.,  Nov., 
'97). 

The  toxic  effects  of  iodoform  are  well 
illustrated  in  the  three  subdivisions  of 
symptoms  proposed  by  McLean: — 

1.  Cutaneous  irritation:  Eruptions  of 
the  skin  in  erythematous  or  eczematous 
form,  associated  with  the  pruritus  of 
urticaria. 

2.  Cerebral  disturbances:  Headache 
often  very  marked;  delirium  more  or  less 
active;  melancholia,  hallucinations;  the 
pupils  occasionally  dilated,  but  more 
often  contracted  and  motionless;  the 
pulse  decidedly  accelerated,  running 
early  up  to  135  to  150  per  minute; 
quality  rather  small  and  wiry;  rapid  in- 
crease of  temperature. 

3.  Syncopal  or  asthenic  form  of 
poisoning:  Patient  overcome  with  dizzi- 
ness, mental  confusion,  great  lethargy; 


IODINE  AND  DERIVATIVES.    UNTOWARD  EFFECTS  OF  IODOFORM. 


weak,  rapid  pulse;  some  paralysis  of  the 
sphincters,  death  coming  sometimes  sud- 
denly by  heart-failure. 

The  quantity  thought  capable  of  caus- 
ing death  has  been  estimated  at  1  drachm 
in  a  case  witnessed  by  Langenstein,  but  it 
is  probable  that  in  the  majority  of  cases 
this  dose  would  not  prove  fatal.  Czerny 
has  reported  a  death  after  1 1/2  drachms 
had  been  taken.  It  is  probable,  however, 
that  the  susceptibility  of  the  patient 
bears  considerable  influence  upon  the  re- 
sults. This  susceptibility  may,  in  turn, 
be  to  a  degree  under  the  influence  of  the 
varying  conditions  of  the  patient's  resist- 
ance, etc.  The  smallest  dose  thought  to 
have  caused  death  (1  drachm)  should 
therefore  be  considered  as  likely  to  give 
rise  to  dangerous  symptoms  in  any  case, 
although  larger  doses  have  been  taken 
with  impunity. 

Case  of  a  woman  who  took  2  drachms 
of  iodoform  at  one  dose,  with  no  evil  re- 
sults. The  only  symptoms  manifested 
were  severe  headache,  griping  pains  in 
the  abdomen,  and  purging.  The  taste  in 
the  mouth  and  the  odor  of  the  drug  in 
the  breath  of  the  patient  remained  for 
several  days.  H.  W.  Frauenthal  (N.  Y. 
Med.  Jour.,  Jan.  11,  '91). 

Treatment  of  Iodoform  Poisoning. — 
The  active  symptoms  of  iodoform  poison- 
ing may  sometimes  be  prevented  by 
timely  measures  when  the  preliminary 
signs  appear.  It  is  important  to  know, 
however,  whether  iodoform  intoxication 
is  really  present.  This  may  be  ascer- 
tained, according  to  Sasse,  by  the  follow- 
ing means: — 

A  test  is  made  of  the  urine  to  note  the 
quantity  of  iodine  which  is  eliminated  by 
it.  A  small  pinch  of  powdered  calomel  is 
placed  upon  a  saucer,  and  then  a  few 
drops  of  the  urine  to  be  examined  are 
dropped  upon  it;  a  mixture  of  the  urine 
and  calomel  is  then  made  with  a  glass 
rod.    If  the  urine  contains  a  notable 


195 

amount  of  iodine  there  is  produced  a 
well  marked  yellow  discoloration,  which 
should  indicate  that  the  iodoform  is 
being  absorbed  in  sufficient  quantity  to 
produce  danger. 

The  immediate  removal  of  the  drug 
from  the  surface  in  cases  of  surgical- 
dressing  intoxication  is  of  obvious  im- 
portance. This  can  easily  be  done  by 
means  of  a  warm  solution  of  starch, 
which  takes  up  all  the  free  iodine  that  is 
present.  Alcohol  and  hot  water  may  be 
used  instead.  The  local  conditions  are 
then  treated  symptomatically,  a  few  doses 
of  bromide  of  potassium  being  given  in- 
ternally to  assist  in  counteracting  the 
poisonous  effects. 

When  a  large  dose  has  been  taken  in- 
ternally, the  stomach  should  be  emptied 
and  20  grains  of  bromide  of  potassium 
given  in  a  half-tumblerful  of  water. 
Four  10-grain  doses  should  then  follow 
every  hour.  This  salt  is  thought  to  be 
a  positive  antidote,  owing  to  its  power  as 
a  solvent  of  chloroform. 

The  antidotal  property  of  potassium 
bromide  explained  by  stating  that  it  ex- 
cells  all  other  salts  in  regard  to  its  sol- 
vent property  for  iodoform.  Samter  and 
Retzlaff  (Wiener  med.  Blatter,  July  11, 
'89). 

Bromide  of  potash  acts  as  an  antidote 
to  iodoform  not  only  as  a  neutral  potash 
salt,  but  also  by  virtue  of  its  specific 
bromide  action.  Joseph  Samter  (Berl. 
klin.  Woch.,  Apr.  15,  '89). 

Twenty-per-cent.  solution  of  bicarbo- 
nate of  potassium  administered  to  a  case 
of  iodoform  poisoning.  The  best  results 
followed,  the  medicine  seeming  to  act  as 
a  direct  antidote.  Behring  (Ther.  Gaz., 
Mar.,  '88). 

Therapeutics. — The  use  of  iodoform 
in  the  treatment  of  wounds  and  ulcer- 
ative processes  has  become  so  general 
that  a  list  of  its  indications  would  serve 
no  useful  purpose.   The  manner  in  which 


196 


IODINE  AND  DERIVATIVES.    IODOFORM.  THERAPEUTICS. 


iodoform  produces  its  effects,  however, 
will  prove  of  practical  interest. 

In  the  powdered  state,  iodoform  has 
been  shown  by  de  Ruyter,  Kronacher, 
Baumgarten,  Heyn,  Drovsing,  and  others 
to  possess  but  little,  if  any,  value  as  an 
antiseptic  in  laboratory  experiments, 
notwithstanding  its  undoubted  value  in 
practice.  It  was  found,  when  mixed 
with  rapidly  infective  bacteria,  in  no  way 
to  reduce  the  development  of  disease  in 
animals.  Even  the  bacillus  tuberculosis, 
though  previously  mixed  with  powdered 
iodoform,  when  introduced  into  guinea- 
pigs  produced  tuberculosis  precisely  as  if 
no  antiseptic  had  been  employed.  Again, 
it  was  found  to  have  no  direct  effect  in 
preventing  the  development  of  staphy- 
lococcus pyogenes,  the  coccus  pneu- 
monia?, or  other  well-known  organisms. 

Far  different  were  the  results,  however, 
when  the  solutions  in  which  decomposi- 
tion of  the  iodoform  has  already  begun 
were  utilized.  Organic  fluids,  blood, 
serum,  in  which  micro-organisms  are 
undergoing  the  process  of  development 
possessing  the  property  of  decomposing 
iodoform,  its  antiseptic  powers,  though 
unexplained,  are  nevertheless  accounted 
for.  In  other  words,  the  properties  of 
iodoform  are  due  to  its  decomposition, 
and  the  activity  displayed  is  proportion- 
ate to  the  energy  of  the  chemico-physical 
process  involved.  Whether  the  decom- 
position is  due,  as  is  believed  by  many,  to 
ptomaines,  local  stimulation,  or  other 
effects  is  not  fully  established. 

Literature  of  '96-'97-'98. 

Tf  wounds  inflicted  on  dogs  or  guinea- 
pigs  are  infected  with  staphylococci  or 
streptococci  and  are  treated  with  iodo- 
form, they  heal  more  quickly  and  secrete 
less  than  those  which  are  not  thus 
treated.  Iodoform  lessens  the  virulence 
of  these  micro-organisms;  neutralizes  or 
destroys  the  microbe  toxins,  hut  not 
completely;   it  does  not  lessen  the  amoe- 


boid motion  or  the  phagocytosis  of  the 
white  blood-corpuscles.  Lomry  (Archiv 
f.  klin.  Chir.,  B.  53,  H.  4,  '96). 

Iodoform  is  not  used  in  surgery  as  it 
was  a  few  years  ago,  although  it  may 
safely  be  said  that,  all  advantages  con- 
sidered, no  drug  has  shown  itself  entitled 
to  its  place.  Its  unpleasant  odor  has 
alienated  the  majority  of  those  who  have 
abandoned  it.  Its  present  status  among 
surgeons  at  large  is  well  represented  by 
the  varying  views  expressed  at  a  recent 
meeting  of  a  surgical  society: — 

Literature  of  '96-'97-'98. 

Use  of  iodoform  is  not  increasing,  but, 
on  the  contrary,  it  is  decreasing.  Ace- 
tanilid  gauze  has  largely  superseded  it. 
T.  G.  Morton. 

The  writer  uses  iodoform  very  little. 
Thymol-diiodide  is  cheaper  and  better  for 
fresh  wounds.  Thymol  and  acetanilid 
are  sufficient  for  nearly  all  cases.  De 
Forest  Willard. 

Not  used  by  writer  as  much  as  for- 
merly, but  it  is  a  very  good  remedy  in 
certain  cases,  as  in  bone-cavities  and  es- 
pecially in  cases  of  abscess  about  the 
rectum,  where  no  packing  can  take  its 
place.  Used  in  the  same  way  in  opera- 
tions about  the  mouth  iodoform  packing 
remains  sweet  longer  than  any  other 
packing.    H.  R.  Wharton. 

The  employment  of  iodoform  in  per- 
sonal practice  limited  to  its  use  as  a 
gauze  for  packing  and  drainage,  espe- 
cially where  dryness  and  antisepsis  are 
required  for  prolonged  periods;  as  an 
injection  in  emulsion  with  glycerin  for 
tubercular  joints  or  abscesses:  and,  oc- 
casionally, in  the  shape  of  a  5-grain  sup- 
pository in  tubercular  affections  of  the 
rectum.    Thomas  8.  K.  Morton. 

There  are  two  classes  of  cases  in  which 
powders  are  used  antiseptically,  one  in 
which  the  drying  element  is  desired  and 
the  other  in  which  antisepsis  is  to  be  ob- 
tained. In  the  latter  case  there  is  not 
anything  to  be  compared  to  iodoform. 
Iodoform  is  the  most  reliable  agent  to 
stop  suppuration  when  actual  contact 
can  be  secured.    G.  G.  Davis. 


IODINE  AND  DERIVATIVES. 


IODOFORM.    THERAPEUTICS.  197 


The  writer  has  not  been  able  to  find 
anything  which  would  take  the  place  of 
icdoform  in  securing  cleanliness  in  a 
moist  cavity.    George  Erety  Shoemaker. 

Routine  use  of  iodoform  to  the  exclu- 
sion of  other  dressings  equally  as  good 
and  free  from  the  many  objections  pro- 
tested against.    W.  G.  Porter. 

Iodoform  is  still  a  valuable  drug.  It 
is  used  nearly  as  much  to-day  as  ten 
years  ago.    R.  H.  Harte. 

The  rational  use  of  iodoform  is  as 
much  indicated  to-day  as  it  ever  was. 
It  is  useful  in  chancroids,  and  nothing 
can  take  its  place.  W.  Joseph  Hearn. 
(Annals  of  Surgery,  May,  '98.) 

Surgical  Tuberculosis. —  It  is  in 
the  treatment  of  tubercular  conditions 
amenable  to  surgical  interference  that 
iodoform  finds  its  main  application  as  a 
curative  agent. 

In  the  treatment  of  joint-tuberculosis 
our  associate  editor,  Dr.  L.  S.  Freeman, 
recommends,  with  many  other  able  sur- 
geons, a  10-per-cent.  suspension  in  olive- 
oil.  His  directions  may  be  summarized 
as  follows:  Absolute  cleanliness  should 
be  observed.  The  iodoform  should  be 
soaked  for  twenty-four  hours  in  a  1  to 
1000  solution  of  bichloride  of  mercury, 
which  is  stirred  occasionally  with  a  glass 
rod  to  make  sure  that  the  solution 
touches  every  particle  of  the  powder.  It 
is  then  filtered,  employing  a  filter-paper 
through  which  has  been  poured  a  quan- 
tity of  boiling  water.  The  remains  of 
the  bichloride  are  then  washed  away 
with  sterilized  water.  The  iodoform  is 
removed  from  the  filter  with  a  surgically- 
clean  knife,  and  rubbed  up  with  the  oil 
in  a  sterilized  mortar,  about  4  per  cent, 
going  into  solution  and  G  per  cent,  re- 
maining in  suspension.  The  oil  is  best 
rendered  germ-free  by  keeping  it  at  the 
boiling-point  for  about  half  an  hour.  If 
the  mixture  is  kept  in  a  dark  place  in  a 
sterilized  bottle  stopped  with  germ-free 


cotton,  it  will  not  deteriorate  for  a  long 
time. 

The  injections  should  be  made  both 
into  the  joint-cavity  and  into  the  sur- 
rounding infected  tissues.  It  is  best  to 
but  partially  withdraw  the  needle  and  in- 
sert it  in  a  new  place  rather  than  to  make 
a  number  of  punctures  in  the  skin. 

If  tubercular  pus  is  present,  it  should 
first  be  withdrawn. 

One  syringeful  of  a  10-per-cent.  sus- 
pension of  iodoform  is  an  average  dose. 
It  is  well  to  begin  with  a  moderate  quan- 
tity and  watch  carefully  for  symptoms  of 
iodoform  poisoning — which,  however, 
seldom  appear. 

In  general,  the  injections  can  be  re- 
peated every  two  or  three  days  over  a 
period  of  several  weeks,  and  then  con- 
tinued at  intervals  of  a  week  or  two. 

The  following  formula  given  for  an 
iodoform  emulsion  for  injection  into 
tuberculous  fistulse:  Iodoform,  3  parts; 
starch,  1  part;  mix  until  a  fine  powder 
is  obtained  and  add  glycerin,  20  parts; 
water,  12  parts;  heat  gradually,  stirring 
the  mixture  constantly,  up  to  271.4°  F. 
The  emulsion  of  10  per  cent,  thus  ob- 
tained is  very  stable,  while  that  ordi- 
narily prepared  by  triturating  iodoform 
in  glycerin  and  heating  is  very  unstable, 
the  iodoform  soon  precipitating.  R.  H. 
Lucy  (Brit.  Med.  Jour.,  Jan.  7,  '93). 

Twenty-one  tuberculous  abscesses,  with 
16  complete  cures,  treated  by  routine  of 
iodoform  in  sterilized  oil  or  glycerol,  a 
10-per-cent.  solution.  Abscesses  in  tuber- 
cular arthritis,  accompanied  with  grave 
suppuration,  were  most  rebellious  to  the 
iodoform  injections.  Four  cases  had 
symptoms  of  poisoning,  2  of  which  had 
attacks  of  acute  nephritis.  Wieland 
(Deut.  Zeit.  f.  Chir.,  xli,  4,  5). 

Literature  of  '96-'97-'98. 

In  39  cases  of  tuberculosis  involving 
the  wrist,  treated  by  iodoform  injections 
after  the  manner  originated  by  Brims, 
24  were  permanently  cured,  while,  with 
15  more,  other  measures  had  to  be  re- 
sorted to. 


198  IODINE  AND  DERIVATIVES.    IODOFORM.  THERAPEUTICS. 


Iodoform  was  used  in  the  form  of  an 
olive-oil  emulsion  of  a  strength  of  10  to 
20  per  cent.,  and  in  the  granulating  form 
of  the  malady  from  30  to  120  minims 
were  injected;  but  where  abscesses  had 
been  emptied,  from  3  to  9  drachms  were 
employed.  Briegel  (Beit.  Z.  klin.  Chir., 
B.  20,  '98). 

In  tubercular  laryngitis  the  local  use 
of  iodoform  has  also  been  followed  by 
excellent  results.  The  ulcerative  sur- 
faces being  carefully  cleared  of  their 
muco-purulent  discharges  by  a  detergent 
spray,  the  ether  solution  of  iodoform 
recommended  by  Elsberg  (1  part  of  ether 
and  4  parts,  crystallized,  of  iodoform, 
shaken  in  a  red  bottle)  is  then  topically 
applied.  This  should  be  repeated  fre- 
quently. In  hemorrhagic  disorders  com- 
plicating tuberculous  processes  it  is  also 
of  value.  In  tubercular  aural  diseases  its 
use  is  as  satisfactory  as  it  is  elsewhere. 

Literature  of  '96-'97-'98. 

Two  cases  of  primary  tuberculosis  of 
the  larynx  cured  by  spraying  with  a 
solution  of  iodoform  in  ether  following  a 
spray  of  cocaine.  To  be  efficient  the 
iodoform  treatment  must  be  adopted 
before  ulceration  takes  place.  Newman 
(Jour,  of  Laryn.,  Mar.,  '96). 

Seven  cases  of  tuberculous  laryngitis 
cured  by  general  treatment  and  lactic 
acid  and  iodoform  locally.  Bernengrun 
(Arch.  Laryn.,  ii,  p.  2;  Quart.  Med. 
Jour.,  Jan.,  '9G). 

Excellent  results  in  two  cases  of  early 
♦  phthisical  hsemoptysis  from  the  use  of 
iodoform  in  eucalyptolized  oil,  beginning 
with  a  daily  dose  of  3/4  grain.  The  hae- 
moptysis ceased  by  the  third  day.  Gallot 
(Gaz.  Hebdom.  de  Med.,  Sept.  1,  '98). 

Internal  Use. — The  employment  of 
iodoform  by  the  month  has  never  re- 
ceived much  support.  In  pulmonary 
tuberculosis  it  has  been  tried  by  many 
clinicians,  but  the  results  have  generally 
been  disappointing,  notwithstanding 
Gosselin's    experiments    showing  that 


guinea-pigs,  when  saturated  with  iodo- 
form, could  stand  with  impunity  inocula- 
tions with  tubercular  material.  Its  use 
in  other  diseases  has  been  barren  of  re- 
sults when  tried  by  several  observers. 
Even  in  syphilis  its  effects  have  not,  as  a 
rule,  been  satisfactory. 

Inunctions.  —  Eecently,  Flick,  of 
Philadelphia,  after  an  experience  of  eight 
years,  has  recommended  the  use  of  iodo- 
form by  inunctions  in  the  treatment  of 
pulmonary  tuberculosis.  Europhen  may 
be  used  instead;  in  fact,  the  last  prepa- 
ration is  preferred  by  the  author.  The 
mixture  is  composed  as  follows:  Iodoform 
or  europhen,  1  drachm;  olei  rosae,  2 
minims;  olei  anisi,  1  drachm;  olei  olivae, 
2  1/2  ounces.  About  a  tablespoonful  of 
the  solution  is  rubbed  into  the  skin  of  the 
inside  of  the  thigh  and  into  the  armpits 
at  night. 

By  means  of  this  treatment,  chiefly 
among  the  out-patients,  he  comes  to  the 
conclusion  (1)  that  incipient  cases  can 
always  be  cured;  (2)  that  cases  advanced 
to  the  breaking-down  stage  may  be  im- 
proved very  much,  and  sometimes  may 
be  cured;  (3)  that  the  treatment  ought 
to  be  continued  even  after  the  acute 
symptoms  have  disappeared,  and  should 
be  maintained  until  perfect  health  is  re- 
established. Flick  gives  creasote  and 
tonics  while  using  the  inunction  treat- 
ment. A  combination  of  the  two  meth- 
ods— viz.,  the  creasote  and  tonic  with  the 
inunction  treatment — gives  better  results 
than  either  separately. 

Substitutes  for  Iodoform. — Quite  a 
large  number  of  substances  have  been 
recommended  as  possessed  of  the  thera- 

I  peutic  properties  of  iodoform,  without 
presenting  its  untoward  features.  The 
best  known  of  these  are  the  following: — 
Airol,  a  gallate  of  bismuth  and  iodine, 
is  a  light-grayish-green  powder,  stable  in 

I  dry  air,  but  when  left  in  contact  with 


IODINE  AND  DERIVATIVES.    SUBSTITUTES  FOR  IODOFORM.  19 9 


moisture  iodine  is  gradually  liberated. 
It  is  insoluble  in  water,  alcohol,  and 
ether.  Airol  is  astringent  and  desic- 
cative,  as  well  as  being  antiseptic. 

Antiseptol  (iodosulphate  of  cincho- 
nine)  is  an  odorous  brown  powder,  which 
has  been  recommended  as  a  substitute 
for  iodoform.  It  contains  half  its  weight 
of  iodine,  and  is  soluble  in  alcohol  or 
chloroform,  but  is  insoluble  in  water. 

Aristol  (di-thymol-iodide)  is  a  reddish- 
brown  powder  containing  45.8  per  cent, 
of  iodine.  It  is  insoluble  in  water,  glyc- 
erin, or  alcohol,  but  soluble  in  ether  or 
oils. 

Aristol  has  been  used  successfully  in 
various  skin  affections:  psoriasis,  eczema, 
rhinitis,  ozsena,  and  lupus,  but  has 
proved  unsatisfactory  in  lichen  rubra, 
soft  chancre,  and  gonorrhoea.  Aristol 
has  a  certain  effect  on  venereal  ulcers, 
but  acts  very  slowly;  the  only  advantage 
it  possesses  over  iodoform  is  absence  of 
smell — its  activity  is  inferior.  It  has 
been  found  of  service  in  the  first  and 
second  stages  of  pulmonary  tuberculosis 
when  no  cavities  exist.  It  also  lessens 
cough  and  night-sweats.  Burns  and 
scalds  have  been  successfully  treated 
with  aristol,  and  the  application  in  a 
powder  to  the  cornea  in  keratitis  and  in 
an  ointment  in  corneal  ulcers  has  given 
good  results.  It  is  of  great  value  in  nasal 
affections;  it  lessens  the  discharge,  re- 
lieves pain,  and  stops  bleeding  when  used 
as  an  insufflation  in  cancer  of  the  cervix 
uteri. 

Di-iodoform  is  an  ethylene-periodate 
and  consists  of  carbon,  4.62  parts;  and 
iodine,  95.38  parts.  It  occurs  in  yellow 
crystals,  is  insoluble  in  water,  slightly 
soluble  in  alcohol  and  ether,  but  dissolves 
readily  in  chloroform,  carbon  disulphide, 
benzin,  and  hot  toluene.  If  kept  in  the 
dark  it  remains  practically  odorless.  The 
compound  is  an  exceedingly  stable  one. 


It  is  said  to  be  well  borne  by  the  stomach 
and  to  be  much  less  toxic  than  iodoform. 

Europhen  (iso  -  butyl  -  ortho  -  cresyl  - 
iodide)  occurs  as  a  pale-orange,  non- 
crystalline powder,  containing  28  per 
cent,  of  iodine. 

Europhen  possesses  powerful  antisep- 
tic properties,  and,  being  resinous  to  the 
touch,  it  adheres  well  to  mucous  mem- 
brane and  wound-surface,  and  does  not 
easily  cake.  It  is  non-poisonous,  and 
acts  only  when  brought  into  contact  with 
secreting  surfaces,  which  decompose  it 
and  liberate  iodine.  It  is  especially  use- 
ful in  dentistry.  Europhen  may  be  used 
with  advantage  in  all  cases  where  iodo- 
form has  been  employed. 

Iodol  (tetra  -  iodo  -  pyrrol)  contains 
about  twenty-seven  parts  in  thirty.  It  is 
obtained  by  precipitating  pyrrol  with 
iodo-iodate  of  potassium.  It  is  a  micro- 
crystalline,  brownish-white  powder,  hav- 
ing a  faint  thyme-like  smell,  and  is 
soluble  in  water.  Iodol  is  said  to  be  non- 
toxic: a  statement  which  should  not  be 
accepted  with  absolute  confidence.  Still, 
that  it  is  much  less  likely  to  produce  un- 
toward symptoms  than  iodoform  is  cer- 
tain. 

Iodol  may  be  used  in  all  conditions  for 
which  iodoform  is  indicated.  It  consti- 
tutes an  excellent  antiseptic  for  all  kinds 
of  ulceration,  including  those  of  a  specific 
nature.  Iodol  has  been  used  with  good 
results  in  gonorrhoeal  affections,  hard 
and  soft  chancres,  and  various  disorders 
of  mucous  membranes,  including  the 
conjunctiva.  It  possesses  some  anaes- 
thetic action,  and  acts  as  an  astringent 
when  the  discharge  is  copious. 

Iodol  possesses  especial  value  for  in- 
ternal medication,  because  it  is  harmless, 
tasteless,  and  odorless,  and  also  because 
of  the  large  amount  of  iodine  contained 
in  it  and  the  free  elimination  of  this 
iodine  in  the  system.  The  author  has 
used  iodol  in  the  treatment  of  scrofulosis, 


200 


IODINE  AND  DERIVATIVES. 


IPECAC. 


diseases  of  the  respiratory  tract,  and  in 
tertiary  syphilis.  In  the  treatment  of 
scrofulosis  the  iodol  was  given  continu- 
ously for  two  or  three  months  in  daily 
doses  of  7  3U  to  23  grains.  In  adenitis, 
besides  the  above  treatment,  a  salve  com- 
posed of  1  part  of  iodol  and  15  parts  of 
vaselin  was  used. 

Inhalations  and  insufflations  were 
added,  with  success,  to  the  internal 
treatment.  Cervesato  (Berl.  klin.  Woch., 
Jan.  14,  '89). 

Literature  of  '96-'97-'98. 

Iodol-ether  is  a  10-  to  20-per-cent. 
ethereal  solution  for  injection  into  fistu- 
lous tracts  and  for  sprays.  By  spraying 
it  upon  the  gauze  with  which  a  wound 
has  been  bandaged  an  excellent  iodol 
gauze  is  had.  (Pharm.  Centralb.,  xxxvii, 
p.  475,  '96). 

Iodol  used  in  about  eight  hundred 
cases  of  soft  and  hard  chancre  and  ero- 
sion of  the  neck  of  the  uterus.  In  soft 
chancre  a  healthy  granulation  was 
quickly  obtained  at  the  base  of  the  ulcer, 
while  in  hard  chancre  the  induration 
quickly  disappeared.  An  important  point 
in  the  treatment,  and  one  essential  to 
its  success,  is  that  the  base  of  the  ulcer 
should  always  be  carefully  cleansed,  in 
order  to  prevent  decomposition  of  the 
iodol.  Majocchi  (Univ.  Med.  Jour.,  Feb., 
'96). 

Iodosalicylic  and  diio  do  salicylic  acids 
are  iodine  compounds  of  salicylic  acid  in 
which  one  and  two  atoms  of  hydrogen, 
respectively,  are  replaced  by  iodine.  Di- 
iodosalicylic  acid  contains  20  parts  of 
iodine  in  30,  iodosalicylic  acid  15  in  30. 
Iodosalicylic  acid  and  diiodosalicylic  acid 
arc  powerful  antiseptics.  They  possess 
the  combined  action  of  iodine  and  sali- 
cylic acid,  and  have  been  successful  in 
the  treatment  of  acute  polyarticular 
rheumatism  where  salicylates  have  failed. 

Loretin  (meta-iodo-ortho-oxy-chinolin- 
ana-sulphonic  acid)  is  a  bright  crystalline 
powder,  odorless,  and  similar  in  appear- 
ance to  iodoform.  It  is  very  slightly 
soluble  in  water  or  alcohol,  and  insoluble 


in  ether,  but  forms  soluble  salts  with 
alkalies,  except  with  lime.  Loretin  is 
non-poisonous  and  unirritating,  and  has 
been  used  with  good  effect  on  burns, 
ulcers,  and  other  wounds. 

Losophan  (meta-tri-iodo-cresol)  con- 
tains 24  parts  of  pure  iodine  in  30.  It  is 
a  grayish  crystalline  powder,  soluble  in 
alcohol,  chloroform,  oils,  and  fats.  Loso- 
phan  has  been  found  useful  in  parasitic 
skin  affections,  but  it  is  apt  to  cause  irri- 
tation. 

Sozoiodol  (di-iodo-para-phenolsulpho- 
nic  acid)  is  composed  of  54  per  cent,  of 
iodine,  7  per  cent,  sulphur,  and  20  per 
cent,  phenol.  Sozoiodol  has  been  found 
useful  in  the  treatment  of  whooping- 
cough:  3  grains  blown  into  each  nostril 
once  daily.  A  solution  of  sozoiodol- 
mercury  with  iodide  of  sodium  has  been 
recommended  for  intramuscular  injec- 
tion in  syphilis.  (Brit.  Med.  Jour.,  Sept. 
18,  >97.) 

Literature  of  '96-'97-'98. 

Iodoformogen  used  as  an  application 
to  recent  wounds.  After  the  bleeding 
had  stopped  the  wounds  were  dusted 
with  the  powder,  then  sewn,  and  a  thin 
layer  of  the  powder  applied  over  all.  The 
wounds  were,  as  a  rule,  rapidly  and  very 
satisfactorily  healed.  Wounds  of  2  centi- 
metres and  larger,  in  which  there  was 
considerable  tension,  were  also  treated 
without  suturing,  in  order  to  see  if  iodo- 
formogen would  be  able,  on  account  of 
its  great  adhesiveness,  to  firmly  adhere 
to  the  margins  and  heal  the  wounds.  As 
a  rule,  excellent  results  were  attained 
in  these  cases.  Schmidt  (Amer.  Medico- 
Surg.  Bull.,  July  25,  '98). 

Charles  E.  de  M.  Sajous, 

Philadelphia. 

IPECAC. — Ipecac  is  the  root  of  the 
Cepha'elis  ipecacuanha  of  A.  Richard:  a 
small  shrub  indigenous  to  Brazil,  and  be- 
longing to  the  Rubiaceo?.    It  is  also  cul- 


IPECAC.    PREPARATIONS  AND  DOSES. 


201 


tivated  in  India.  Ipecacuanha  contains 
an  alkaloid  called  emetine,  a  glucoside 
called  ipecacuanhic  acid  which  resembles 
quinic  and  caffe-tannic  acids,  gum,  resin, 
starch,  a  volatile  oil,  lignin,  and  sugar. 
The  powdered  root  has  a  slight,  but  char- 
acteristic, nauseous  taste.  The  alkaloid, 
emetine,  usually  described  as  white  in 
color,  is  more  usually,  as  noted  by  Merck, 
a  light  brownish,  crystalline  powder,  of 
a  bitter  taste,  and  darkening  upon  ex- 
posure. It  is  soluble  in  alcohol  and 
chloroform,  slightly  soluble  in  ether, 
and  very  slightly  soluble  in  water.  It  is 
present  in  the  root  in  a  proportion  of 
somewhat  less  than  1  per  cent. 

The  presence  of  three  distinct  alkaloids 
has  been  indicated  in  ipecacuanha.  The 
powdered  drug  is  exhausted  with  alcohol, 
treated  with  basic  lead  acetate,  and  fil- 
tered; the  filtrate  is  evaporated  to  dry- 
ness and  the  residue  so  obtained  dis- 
solved in  dilute  H2S04.  After  the  filtra- 
tion the  clear  solution  is  treated  with  am- 
monia. The  ammoniacal  liquor  is  then 
shaken  with  ether,  which  removes  the 
two  principal  alkaloids,- — cephseline  and 
emetine.  The  third,  existing  in  very 
small  quantity,  remains  in  the  alkaline 
liquid,  from  which  it  may  be  removed 
by  chloroform.  It  is  a  yellow  crystalline 
body.  Cephseline  and  emetine  are  sepa- 
rated by  a  solution  of  caustic  alkali,  the 
former  alkaloid  being  soluble  in  that 
liquid.  Cephseline  (CuH2oN02)  is  a 
crystalline,  monacid  base,  forming  crys- 
talline salts.  Emetine  (C15H22N02)  is  a 
non-crystalline,  monacid  base;  it,  how- 
ever, forms  very  well  defined  crystalline 
salts.  Both  alkaloids  in  the  free  state 
are  colorless,  but  are  decomposed  by 
light  and  turn  yellow;  their  salts,  on 
the  other  hand,  are  perfectly  stable  and 
afford  a  means  of  administering  these 
substances  unaltered. 

The  so-called  ipecacuanhic  acid  is,  in 
all  probability,  a  mixture  of  a  glucoside 
resembling  saponin  and  a  substance  giv- 
ing a  dark-green  color-reaction  with 
FeCl3.  Paul  and  Cownley  (Pharm.  Jour, 
and  Trans.,  London,  vol.  liii,  p.  CI ;  vol. 
liv,  pp.  Ill,  373,  GOO). 


Preparations  and  Doses. — The  pow- 
dered root  of  ipecacuanha,  1/2  to  30 
grains. 

The  fluid  extract  (Extractum  ipecac- 
uanha? fluidum),  1  minim  to  1  flu- 
idrachm. 

The  syrup  (syrupus  ipecacuanha?),  5 
minims  to  6  fluidrachms. 

The  wine  (vinum  ipecacuanha?),  5 
minims  to  1  fluidrachm. 

The  tincture  of  ipecac  and  opium 
(tinctura  ipecacuanha?  et  opii),  5  to  15 
minims. 

The  troches  of  ipecacuanha  (trochesci 
ipecacuanha?),  1  to  2  troches. 

The  troches  of  morphine  and  ipecacu- 
anha? (trochesci  morphina?  et  ipecacu- 
anha?), 1  to  2  troches. 

The  powder  of  ipecac  and  opium  (pul- 
vis  ipecacuanha?  et  opii — Dover's  pow- 
der), 5  to  15  grains. 

Emetina,  non-official,  1/120  to  1/8  grain. 
Emetina?    hydrochloras,  non-official, 
7i2o  to  78  grain. 

Physiological  Action. — Ipecac  when 
applied  locally  to  the  mucous  membranes 
and  to  the  skin  acts  as  an  irritant.  It 
gives  rise  to  a  papular  eruption,  which 
becomes  pustular  and  proceeds  to  active 
ulceration  if  the  application  is  persisted 
in.  Internally,  small  doses  frequently  re- 
peated give  rise  to  nausea  and  increased 
flow  of  saliva  and  bronchial  secretions. 
In  persons  sensitive  to  its  influence  ver- 
tigo and  flushing  may  appear  in  addition. 
Peculiar  case  of  idiosyncrasy  to  ipecac. 
Nausea,  vertigo,  and  flushing  of  the  face 
manifested  themselves  after  the  adminis- 
tration of  a  little  less  than  2  drops  of  the 
wine  of  ipecac.    Ernest  Sangree  (Times 
and  Register,  Aug.  10,  '89). 

Iii  large  closes  these  effects  are  in- 
creased in  intensity,  and  vomiting  occurs 
without  producing  excessive  prostration, 
an  excess  of  the  drug  being  ejected  be- 
fore it  has  had  time  to  induce  very  de- 
pressing effects. 


202 


IPECAC.    POISONING.  THERAPEUTICS. 


These  effects  are  mainly  due  to  cephse- 
line  and  emetine,  as  the  two  principal 
alkaloids  of  ipecacuanha  possess — as 
shown  by  E.  B.  Wild — a  powerful  emetic 
action;  the  emetic  dose  of  the  latter  (the 
hydrochloride)  is,  however,  about  double 
that  of  the  former.  In  non-emetic  doses 
the  degree  of  nausea  produced  by  cephae- 
line  is  also  about  double  that  produced 
by  emetine, — e.g.,  the  intensity  and  dura- 
tion of  nausea  following  cephgeline  are 
much  the  same  as  that  following  double 
the  amount  of  emetine.  Both  alkaloids 
lower  arterial  tension,  and  little  differ- 
ence is  apparent  in  small  doses,  but  the 
depression  produced  by  cephaaline  is  less 
than  that  produced  by  the  larger  emetic 
dose  of  emetine.  They  cause  contraction 
of  the  blood-vessels  after  destruction  of 
the  brain  and  spinal  cord;  but  emetine 
is  distinctly  more  active  than  cephaeline: 
1  in  10,000  of  the  latter  produces  little, 
if  any,  effect,  while  1  in  20,000  of  emetine 
is  followed  by  marked  contraction.  Ceph- 
aeline  is  practically  free  from  depress- 
ing effects  when  given  in  doses  of  1/16 
to  V6  grain,  but  its  action  as  an  emetic 
is  slow. 

The  irritating  action  of  the  drug  upon 
the  stomach  is  thought  to  represent  the 
most  active  factor,  though  d'Ornellas  has 
shown  that  hypodermic  injections  of 
emetine  also  produce  emesis  in  animals. 
The  action  upon  the  central  nervous  sys- 
tem has  not  been  established,  but  the 
contradictory  evidence  available  would 
tend  to  show  that  it  is  but  slightly  influ- 
enced. It  tends  to  depress  cardiac  action 
and  has  caused  death  in  animals  by  para- 
lyzing the  heart.  The  pulmonary  system 
seems  to  be  depleted  of  its  blood,  judging 
from  the  pallor  of  the  tissues  post- 
mortem, an  active  hyperamiia  of  the  gas-  I 
tro-intestinal  tract  apparently  acting  as 
compensating  factor. 

Poisoning-  by  Ipecacuanha.  —  In  the  | 


lower  animals  lethal  doses  of  emetine 
cause  death  by  paralysis  of  the  muscles 
of  respiration,  the  heart  continuing  to 
functionate  after  respiratory  movements 
have  ceased.  The  surface-temperature 
falls,  but  the  internal  temperature  either 
remains  stationary  or  suffers  a  slight  rise, 
owing  to  the  irritant  action  of  the  em- 
etine upon  the  intestinal  mucous  mem- 
brane (d'Ornellas). 

Post-mortem  examination  of  animals 
killed  by  emetine  reveals  considerable 
gastro-intestinal  irritation. 

Case  of  a  woman,  48  years  of  age,  suf- 
fering from  bronchitis,  to  whom  a  6- 
ounce  mixture  containing  1  ounce  of  the 
syrup  of  ipecacuanha  was  administered. 
The  patient  was  immediately  seized  with 
a  violent,  obstinate,  and  prolonged  attack 
of  vomiting  each  time  she  took  a  tea- 
spoonful  of  the  mixture.  So  susceptible 
was  the  woman  to  the  smallest  quantity 
of  the  drug,  that  it  had  to  be  omitted 
from  the  cough  -  mixture  altogether. 
Several  experiments  tried  on  the  same 
case,  always  with  the  same  result,  though 
somewhat  modified  by  the  quantity  used 
in  each  dose.  The  patient  suffered  from 
no  other  bad  effects  of  the  ipecacuanha. 
E.  L.  Morgan  i  (Va.  Med.  Monthly,  July, 
'92). 

The  lungs  are  generally  hyperaemic 
and  present  patches  of  hepatization;  less 
frequently  they  are  exsanguinated.  The 
internal  use  of  ipecacuanha  is  sometimes 
followed  by  urticaria. 

Treatment  of  Poisoning  by  Ipecacu- 
anha.— Poisoning  by  ipecac  or  its  alka- 
loid, emetine,  is  rare.  The  indications, 
however,  are  to  remove  the  drug  from  the 
stomach,  if  possible,  by  means  of  the 
stomach-pump.  External  heat,  whisky, 
ammonia,  strychnine,  and  other  respira- 
tory stimulants  should  be  resorted  to. 

Therapeutics. — Ipecac  is  a  safe  and 
efficient  emetic.  It  is  free  from  depress- 
ing and  irritating  effects  when  given  in 
ordinary  doses.  On  the  other  hand,  it  is 
sometimes  slow  in  its  action.    Ipecac  in 


IPECAC.  THERAPEUTICS. 


203 


emetic  doses  (4  to  20  grains  of  powder 
or  1  to  3  drachms  of  the  syrup)  may  be 
used  to  empty  the  stomach  in  cases  of 
acute  indigestion,  migraine,  or  bilious 
sick  headache.  In  membranous  croup, 
asthma,  capillary  bronchitis,  lodgment 
of  foreign  bodies,  pertussis,  and  in  laryn- 
gismus stridulus  it  may  be  employed  in 
emetic  doses  for  its  mechanical  effects. 
In  the  bronchitis  of  small  children,  who 
swallow  the  mucus  coughed  up  from  the 
lungs  instead  of  spitting  it  out  of  the 
mouth,  emetic  doses  of  ipecac  will  relieve 
the  stomach  and  improve  the  condition 
of  the  lungs. 

As  an  emetic  in  cases  of  poisoning  it  is 
inferior  to  mustard  or  the  sulphate  of 
zinc  or  copper  on  account  of  its  less  effi- 
cient and  slower  action. 

As  an  antemetic,  in  small  doses  (1/10 
to  V4  grain  of  powder  or  1/2  to  1  minim 
of  wine)  repeated  every  half-hour  or 
hourly,  ipecac  holds  a  high  place.  Given 
in  this  way  we  find  ipecac  useful  in  ob- 
stinate vomiting  of  drunkards,  in  the 
vomiting  of  pregnancy,  the  vomiting  of 
migraine,  and  especially  in  nervous 
vomiting  and  the  morning  vomiting 
which  sometimes  accompanies  general 
weakness  of  convalescents  from  acute  dis- 
eases. In  the  vomiting  of  children,  with 
acute  catarrh  of  the  stomach,  ipecac  is 
useful.  Ringer  notes  that  ipecac  has  a 
greater  influence  over  the  vomiting  of 
children  than  over  that  of  adults.  The 
vomiting  occurring  with  cancer  of  the 
stomach  is  sometimes  relieved  by  ipecac 
after  the  more  commonly  used  remedies 
have  failed  (Ringer).  Small  doses  (yi0 
to  3/6  grain  of  ipecac)  are  found  bene- 
ficial where  insufficient  excretion  of  bile 
and  torpor  of  the  liver  are  present.  In 
flatulent  dyspepsia  small  doses  (Vio  to 
V4  grain)  given  after  meals  are  followed 
by  a  subsidence  of  the  flatulence.  One 
grain  of  pulverized  ipecac  taken  fasting 


every  morning  will  remove  the  dyspepsia 
associated  with  constipation,  depressed 
spirits,  flatulence,  cold  extremities,  and 
a  feeling  of  weight  in  the  stomach. 

Literature  of  '96-'97-'98. 

Case  of  a  woman  who  had  been  subject 
to  epileptic  fits  from  the  age  of  eight 
years.  She  had  been  more  or  less  under 
treatment.  Finally  the  bromide  was  re- 
duced to  a  third  of  the  former  dose  and 
vinum  ipecacuanhas  added.  A  commenc- 
ing dose  of  10  minims  was  increased  from 
time  to  time  as  the  fits  recurred,  until 
40  minims  three  times  a  day  were  given. 
The  severity  and  frequency  of  the  fits 
diminished  under  this  treatment  until 
May  3,  '98,  since  when  no  fits  have  oc- 
curred. C.  Knox  Bond  (Lancet,  Sept.  17, 
'98). 

Disorders  of  the  Respiratory 
Tract. — In  the  early  stage  of  bronchitis, 
when  the  secretion  from  the  lungs  is 
abundant  and  tenacious,  ipecac  will  do 
good  service  in  non-emetic  doses.  Mur- 
rell  and  Ringer  recommend  the  inhala- 
tion of  wine  of  ipecac,  in  the  form  of  a 
spray  produced  by  a  hand-atomizer,  in 
the  treatment  of  winter-cough  and  bron- 
chial asthma.  The  wine  may  be  used 
pure  or  diluted  with  1  or  2  parts  of  water. 
At  the  first  application  it  sometimes  ex- 
cites a  paroxysm  of  coughing,  which  gen- 
erally soon  subsides;  but,  should  it  con- 
tinue, a  weaker  solution  should  be  used. 
As  a  rule,  the  patient  at  first  will  bear 
about  20  compressions  of  the  bulb  with- 
out nausea.  The  inhalation  should  be 
used  at  first  daily,  and  in  bad  cases  two 
or  three  times  daily,  afterward  every 
other  day  suffices,  and  the  interval  may 
be  gradually  extended.  As  the  spray  is 
used  for  its  topical  effect,  the  patient  is 
directed  to  spit  out,  or  even  to  rinse  out, 
the  mouth  at  each  pause  in  the  adminis- 
tration, for  a  much  larger  quantity  of 
the  wine  collects  in  the  mouth  than 


204: 


IPECAC.  THERAPEUTICS. 


passes  into  the  lungs.  In  this  way  nausea 
and  even  vomiting  are  avoided. 

Spray  of  ipecacuanha  has  given  suc- 
cessful results  in  chronic  bronchitis  and 
bronchial  catarrh.  A  single  inhalation 
will  sometimes  restore  the  voice  in 
hoarseness  due  to  congestion  of  the  vocal 
cords,  and  most  cases  of  winter-cough 
will  be  relieved  in  ten  days.  The  spray 
should  be  used  warm  for  about  ten  min- 
utes three  to  four  times  a  day,  and  the 
patient  should  not  go  out  for  some  min- 
utes after  inhaling.  Either  a  hand-ball, 
spray-apparatus,  or  a  steam-vaporizer 
may  be  employed.  W.  Murrell  (Med. 
Press  and  Circular,  Apr.  25,  '88). 

Hemorrhage. — Ipecac  possesses  un- 
disputed antihsemorrhagic  properties.  It 
may  be  used  alone  or  combined  with 
ergot  or  some  other  antihasmorrhagic 
agent.  For  this  purpose  ipecac  should  be 
given  in  frequently-repeated  doses  until 
vomiting  ensues.  It  has  been  success- 
fully used  in  haemoptysis,  epistaxis,  men- 
orrhagia,  post-partum  haemorrhage,  etc. 

Ipecacuanha  in  emetic  doses  of  15 
grains  every  ten  minutes  is  the  most 
powerful  haemostatic  in  severe  haemopty- 
sis of  phthisical  patients.  C.  Bernabei 
(Boll,  della  sez.  della  Sci.  Med.,  No.  2, 
'87). 

The  wine  of  ipecac  given  in  doses  of  10 
to  15  grains  has  been  successfully  used  in 
uterine  inertia  in  the  first  and  second 
stages  of  labor. 

Intestinal  Disorders. — In  acute 
dysentery  ipecac  is  especially  efficient. 
When  the  passages  are  large  and  bloody 
and  the  type  is  malignant,  60  to  90  grains 
are  given  first  to  produce  vomiting.  After 
vomiting  has  been  induced  small  doses 
of  2  to  3  grains  are  given  every  hour,  and 
continued  until  a  profuse  black  stool 
occurs.  This  latter  is  a  favorable  prog- 
nostic sign;  its  non-appearance  is  signifi- 
cant of  danger.  The  great  depression  is 
counteracted  by  the  free  exhibition  of 
stimulants,  and  the  vomiting  by  the  use 


of  opium  and  sinapisms  to  the  epigas- 
trium. 

Case  of  dysentery  of  diphtheritic  type 
in  which  there  was  steady  deterioration 
under  the  use  of  opium  and  almost  in- 
stant improvement  and  eventual  recovery 
under  the  use  of  ipecac.  R.  P.  Jones 
(Dublin  Jour.  Med.  Science,  Aug.  1,  '94). 

In  choleraic  diarrhoea  and  cholera 
morbus  ipecac,  in  dose  of  3  grains,  given 
every  two  hours,  is  followed  by  good  re- 
sults. 

Skin  Disorders. — Ipecac  is  excreted 
in  part  by  the  skin  (Binz),  and  we  find 
that  its  diaphoretic  properties  may  be 
utilized  in  the  beginning  of  fevers,  colds, 
and  other  inflammatory  conditions,  for 
which  purpose  it  is  associated  with  opium 
as  in  the  official  "pulvis  ipecacuanha  et 
opii."  In  the  dermatitis  caused  by  rims 
toxicodendron  the  free  application  of  a 
wash  consisting  of  3  drachms  of  powdered 
ipecac  to  a  pint  of  water  is  recommended 
by  W.  S.  Gilmore.  Neall  recommends 
the  use  of  1  pint  of  powdered  ipecac  to 
8  parts  each  of  alcohol  and  ether  to  re- 
lieve the  inflammation  caused  by  mos- 
quito-bites. Powdered  ipecac  made  into 
a  paste  and  smeared  on  the  skin  is  said  to 
relieve  the  pain  and  swelling  produced 
by  the  sting  of  bees. 

Literature  of  '96-'97-'98. 

Ipecacuanha  tried  several  years  in 
Nicaragua.  Central  America;  notwith- 
standing its  vaunted  efficacy,  in  dysen- 
tery no  case  derived  much  benefit  from 
it,  Patients  suffering  from  dysentery 
could  not  always  retain  the  large  doses 
recommended  in  text-books.  But  W 
ounce  doses  of  a  saturated  solution  of 
magnesium  sulphate  and  15  minims  of 
dilute  sulphuric  acid  every  two  hours, 
with  milk  diet,  caused  all  traces  of  blood 
to  disappear  from  the  stools  in  twenty- 
four  hours,  and  there  was  a  complete 
absence  of  the  distressing  nausea  which 
is  always  present  in  the  treatment  by 
ipecacuanha.    T.  R.  Wiglesworth  (Brit. 


IRIS,  CILIARY  BODY,  AND  CHOROID.    ANOMALIES.  ANIRIDIA. 


205 


Med.  Jour.,  Feb.  26,  '98).  (See  Dysen- 
tery, volume  iii.) 

Ipecacuanha  used  in  about  50  cases  of 
anthrax  during  the  last  fifteen  years  and 
without  a  single  failure.  The  writer  ap- 
plies it  externally,  mixed  with  water  to 
the  consistence  of  cream,  and  administers 
it  in  full  doses  internally.  In  carbuncle, 
too,  it  appears  to  be  a  specific.  E.  B. 
Muskett  (Lancet,  Feb.  11,  '89). 

C.  Sumner  Witherstine, 

Philadelphia. 

IRIDECTOMY.    See  Cataract. 

IRIS,  CILIARY  BODY,  AND  CHO- 
ROID, DISORDERS  OF. — The  iris,  cil- 
iary body,  and  choroid,  constituting  the 
"uveal  tract," — the  vascular  or  nutritive 
coat  of  the  eye, — are  best  considered  to- 
gether. 

The  inflammations  and  degenerations 
that  commonly  affect  the  uveal  tract  are 
especially  dependent  on  constitutional 
conditions. 

Anomalies  of  the  Iris  and  Choroid. — 
Albinism. — Absence  of  pigment  in  the 
uveal  tract  accompanies  the  lack  of  pig- 
ment in  the  hair  and  skin  throughout 
the  body.  The  iris  has  a  dull,  gray-blue 
color,  the  pupil  by  ordinary  illumination 
may  appear  red.  With  the  ophthal- 
moscope, red  fundus-reflex  may  be  seen 
through  the  iris,  and  the  choroidal  ves- 
sels are  distinctly  visible  against  the  yel- 
lowish-white background  of  the  sclera. 
Such  eyes  usually  present  high  errors  of 
refraction,  for  which  correcting  lenses 
should  be  worn. 

Instance  of  partial  albinism  of  the  iris 
in  a  man,  57  years  old,  who  showed  evi- 
dences of  an  anterior  chorioretinitis  com- 
plicating a  peripapillary  choroiditis.  By 
focal  illumination  the  iris  presented  a 
uniform  coloration ;  its  anterior  layers 
were  normal,  and  there  were  no  signs  of 
pathological  change.  When  light  was 
thrown  into  the  eye,  however,  by  the 
minor  of  the  ophthalmoscope,  the  in- 
ferior half  of  the  iris  permitted  the  rays 


to  pass  through  its  meshes.  Thought  to 
be  due  to  congenital  lack  of  development. 
Dujardin  (Jour,  des  Sciences  Med.  de 
Lille,  Jan.  6,  '93). 

Light  irides  held  to  be  a  variety  of 
albinism,  an  arrest  of  development  of  the 
pigment-granules,  arising  from  an  im- 
perfect nutrition  of  the  anterior  section 
of  the  eye.  Malgot  (Rec.  d'Ophtal.,  Aug., 
'95). 

Axibidia  is  complete  absence  of  the 
iris. 

Instance  of  traumatic  aniridia  where 
the  iris  had  slipped  under  the  conjunctiva 
through  a  rupture  in  the  sclera.  By 
reason  of  the  malposition  of  the  iris  it 
was  possible  to  see  the  ciliary  processes 
elongate  under  the  use  of  eserine.  The 
visual  field  was  not  larger  than  normal. 
Wintersteiner  (Inter,  klin.  Rundschau. 
Aug.  23,  '93). 

Case  of  traumatic  aniridia;  no  in- 
convenience save  from  excessive  light. 
Rene  (Gaz.  des  Hop.,  Oct.  9,  '94). 

Case  of  traumatic  aniridia  with  con- 
servation of  lens.  Ahlstroem  (Beitrage 
z.  Augenh.,  vol.  xvi,  '94). 

Literature  of  '96-'97-'98. 

Partial  aniridia  and  corectopia  (slit- 
shaped  pupil)  represent  a  non-develop- 
ment of  the  arteries  which,  springing  out 
into  the  anterior  chamber  from  the  major 
circle  of  the  iris,  collect  about  them  the 
tissue  that  makes  up  the  iris-stroma. 
W.  C.  Posey  (Arch,  of  Ophth.,  July,  '97). 

Cause  of  congenital  irideremia  is  lack 
(usually  hereditary)  of  sufficient  forma- 
tive material  for  the  development  of  the 
eye.  Matthias  La  nekton  Foster  (Ar- 
chives of  Ophth.,  Nov.,  '98). 

Congenital  aniridia  indicates  a  strong 
tendency  to  hereditary  transmission. 
While  focal  illumination  may  not  reveal 
any  trace  of  iris,  the  microscope  has 
shown  that  there  is  always  a  rudimentary 
iris  present.  The  cornea  is  generally  full 
sized,  but  may  be  smaller  than  normal. 
The  cornea  may  be  clear,  but  in  most  in- 
stances shows  some  pathological  change. 
There  may  be  anterior  or  posterior  polar 
or  lamellar  cataract:  and  the  lens  is  fre- 
quently displaced.  The  lens  may  remain 
clear  for  some  time,  but  some  form  of 


/ 


206 


IRIS,  CILIARY  BODY,  AND  CHOROID.    ANOMALIES.  ANIRIDIA. 


cataract  will  generally  develop  before 
puberty.  Nystagmus  is  present  in  some 
cases.  The  fundus  may  be  normal. 
Changes  in  the  choroid  have  frequently 
been  observed. 

In  aniridia  opaque  lenses  should  be 
removed  as  soon  as  possible.    When  the 
lens  is  displaced,  according  to  the  indi- 
cations of  the  case,  either  a  discission  or 
extraction    is    indicated.     A    low  de- 
gree of  increased  tension  following  the 
discission  or  extraction  may  yield  to 
myotics.    If  the  tension  should  not  yield 
to  eserine  or  pilocarpine,  then  anterior 
sclerotomy  must  be  done.    Joseph  An- 
drews (Ophthalmic  Record,  Nov.,  '98). 
Coloboma  of  the  iris  is  an  extension  of 
the  pupil  usually  downward.  Displace- 
ment of  the  pupil  is  called  "corectopia." 


ophthalmometric  examination  Antonelli 
(Annali  di  Ottal.,  vol.  xxii,  Nos.  2  to  5, 
'94). 

Coloboma  of  the  choroid  is  a  con- 
genital lack  of  choroid  in  some  part  of 
the  fundus.  Sometimes  it  is  merely  a 
rounded  area  through  which  the  sclera 
is  seen;  sometimes  it  extends  from  the 
equator  of  the  eye  back  to  or  including 
the  optic  disk.  It  is  to  be  distinguished 
by  its  smooth,  rounded  margin  from 
patches  of  choroidal  atrophy,  or  retinal 
exudation. 

Microscopical  examination  of  a  case  of 
typical  inferior  coloboma  of  the  iris  show- 
ing a  cleft  in  the  pigment-epithelium  of 
the   ciliary   process,   the   pars  ciliarias 


Right  eye.    Cataract  mature. 


Left  eye.    Cataract  immature. 


Congenital  irideremia  with  both  lenses  displaced  upward.  Actual  size  of 
cornea  and  lens  :  Vertical  diameter,  9  millimetres  ;  horizontal  diameter,  10  milli- 
metres ;  distance  between  pupillary  centres,  as  in  above  drawing,  i.e.,  61  milli- 
metres.   ( Andrews. ) 


Case  of  congenital  double  corectopia, 
in  a  man  aged  45.  The  pupils  wTere  situ- 
ated above  and  in;  the  right  had  the 
form  of  a  rectangle,  rounded  at  the 
angles,  and  the  left  was  slit-like  in  char- 
acter. There  was  also  luxation  of  both 
lenses,  and  an  atrophic  retinochoroiditis. 
The  patient  had  light-perception  in  the 
right  eye.  There  were  no  other  malfor- 
mations. Fromaget  (Jour,  de  Med.  de 
Bordeaux,  Dec.  6,  '91). 

Corneal  reflexes  studied  in  several 
cases  of  bilateral  corectopia  by  means  of 
Javal's  ophthalmometer.  It  was  found 
that,  in  spite  of  a  marked  degree  of 
eccentricity  of  the  pupil,  a  part  of  that 
aperture  always  enters  upon  the  corneal 
zone,  which  is  more  or  less  central  and 
is   always   included    during   the  usual 


retinae  being  continuous  with  the  colo- 
boma of  the  iris.  The  walls  of  the  colo- 
boma, which  were  turned  outward,  con- 
tained no  trace  of  the  sphincter  pupillse. 
The  connective  tissue,  the  mesoblastic 
portion  of  the  ciliary  process  filling  the 
space,  showed  no  signs  of  previous  in- 
flammation. In  the  pupillary  space 
proper  there  were  numerous  fibres  and 
tracts  of  spindle-cells  extending  out  upon 
the  lens-capsule  (persistent  pupillary 
membrane).  The  posterior  capsule  was 
normal.  The  cause  of  the  non-closure  of 
the  footal  cleft  was  not  evident  by  micro- 
scopical examination.  Holden  (Archives 
of  Ophthal..  Oct.,  '92). 

Persistent  pupillary  membrane, 
the  remains  of  the  fibro-vascular  mem- 


the  Daughter: 

Her  Health,  Education,  and 
Wedlock. 

maidenhood. 
(Uifebood. 
motfterbool 

«««««««««« 

By 

WlLkHlAJW  JVI.  CflPP,  jvr.D., 

Philadelphia. 


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IRITIS;  CYCLITIS;  IRIDOCYCLITIS. 


207 


brane  which  closes  the  pupil  during  early 
foetal  life,  appears  as  one  or  more  threads 
that  stretch  across  the  pupil,  or  from  the 
iris  to  an  opaque  area  of  the  lens-capsule 
within  the  pupil.  They  are  distinguished 
from  posterior  synechia  by  the  fact  that 
they  arise  not  from  the  margin  of  the 
pupil,  but  from  the  front  of  the  iris  at 
some  little  distance  from  the  pupillary 
margin. 

Polycokia,  multiple  pupils,  may  be 
caused  by  division  of  the  normal  pupil 
into  two  by  a  band  of  persistent  pupillary 
membrane,  or  it  may  be  from  openings 
in  other  parts  of  the  iris.  Only  the  cen- 
tral or  true  pupil  is  furnished  with  a 
sphincter  muscle. 
Iritis ;  Cyclitis ;  Iridocyclitis. 
Plastic  inflammation  of  the  iris  and 
ciliary  body  includes  iritis,  cyclitis, 
iridocyclitis,  parenchymatous  and  serous 
iritis,  and  the  varieties  of  iritis  named 
syphilitic,  rheumatic,  etc.,  according  to 
the  supposed  cause. 

Symptoms. — Pain  in  and  about  the 
eye  becoming  severe,  worse  at  night,  and 
preventing  sleep,  is  rarely  absent.  Ked- 
ness  is  seen  in  the  pericorneal  zone;  and 
the  color  of  the  iris  is  altered  and  the 
pupil  contracted  by  hyperemia.  The 
iris  is  thickened  and  its  surface  dull. 
Vision  is  impaired  by  haziness  of  the 
media,  plastic  exudate  causes  the  iris  to 
adhere  to  the  anterior  capsule  of  the  lens, 
posterior  synechia.     When  the  ciliary 
body  is  much  involved,  dots  of  exudate 
are  deposited  on  the  posterior  surface  of 
the  cornea,  usually  on  a  triangular  area 
at  the  lower  part,  "keratitis  punctata"; 
and  the  ciliary  region  is  tender  to  touch. 
The  incipient  symptoms  of  syphilitic- 
iritis  are  generally  very  insidious,  and 
consist  in  subjective  sensations  of  light 
rather   than   failure   of   visual  power. 
Almost  every  part  of  the  eye  is  more  or 
less    affected.     The   retinitis    may  be 
monolateral.   Hirschberg  (Deutsche  med. 
Woeh.,  Oct.  25,  '88). 


Literature  of  '96-'97-'98. 

The  cornea  is  affected  in  every  case  of 
iritis.  In  no  case  does  it  retain  its  per- 
fect transparency.  The  opacities  consist 
of  deposits  upon  Descemet's  membrane 
and  infiltrations  in  the  substantia 
propria.  It  is  these  deposits  which  cause 
the  pupil  and  iris  to  appear  blurred  and 
hazy,  and  which  are  often  referred  to  as 
muddiness  of  the  aqueous  humor.  Frie- 
denwald  (Arch,  of  Ophth.,  Apr.,  '96). 

Two  cases  of  painful  iritis.  In  both 
the  only  sign  of  iritis  was  a  slight  slug- 
gishness of  the  pupil.  There  was  almost 
no  injection,  and  what  was  present  was 
not  characteristic.  In  the  first  case 
synechias  were  found  and  the  pupil  was 
irregular.  In  the  second  the  whole  pupil- 
lary border  was  adherent  to  the  lens. 
Walker  (Phila.  Polyclinic,  Jan.  9,  '97). 

The  synechias  prevent  the  dilatation  of 
the  pupil  under,  a  mydriatic,  which  there- 
fore becomes  irregular  in  shape.  In  a 
few  cases  general  adhesion  of  the  iris  to 
the  lens  occurs  without  much  pain  or 
redness  of  the  eye. 

Etiology. — Iritis  may  be  caused  by 
traumatism,  but  usually  arises  from 
some  dyscrasia.  Half  of  all  cases  are  due 
to  syphilis;  other  causes  in  the  order  of 
their  frequency  are  rheumatism,  anemia, 
acute  febrile  diseases,  diabetes,  gonor- 
rhoea, gout,  and  new  growths  in  the  iris. 
In  syphilis  it  occurs  in  the  secondary 
stage  within  a  year  after  infection.  With 
rheumatism  it  may  occur  with  or  be- 
tween other  manifestations  of  the  dis- 


It   arises   during  convalescence 


ease, 
from  acute  fevers 


Curious  case  of  grave  iritis,  evoked  by 
the  hairs  of  a  caterpillar,  which  had 
penetrated  into  the  interior  of  the  eye. 
Weiss  (Archiv  f.  Augenh.,  Aug.,  '89). 

Case  in  which  a  stone  splinter  remained 
in  the  iris  for  thirty-one  or  thirty- two 
years  without  causing  any  inflammatory 
reaction.  Rieke  (Zehender's  klin.  Mon- 
ats.  f.  Augenh.,  Sept.,  '90). 

Case  of  successful  extraction  of  a  piece 
of  steel  from  an  iris  in  which  a  plastic 
inflammation  had  been  established,  with 


IRITIS;  CYCLITIS;  IRIDOCYCLITIS. 


prompt  subsidence  of  the  inflammatory 
reaction  and  restoration  of  full  vision. 
Heckel  (Bull,  de  la  Soc.  de  Med.  de 
Rouen,  Oct.,  '95). 

Catheterization  of  the  urethra  followed 
by  an  abscess  of  a  testicle.  Six  months 
later,  after  catheterization,  patient  had  a 
chill  and  fever,  and  in  twelve  days  a 
purulent  iritis.  The  inflammation  in- 
creased and  in  a  short  time  the  ball  was 
filled  with  pus.  Starting  from  the  iris, 
the  infection  spread  to  every  structure 
of  the  eye.  Inflammation  attributed  to 
a  lodgment  of  microbes.  Trousseau 
(Ann.  d'Oculist.,  Mar.,  '94). 

The  various  forms  of  iritis  are  all  in- 
fectious. Where  the  condition  occurs  as 
a  result  of  syphilis,  etc.,  it  may  be  re- 
garded as  an  attempt  at  elimination  by 
the  gland  (the  uveal  tract  being  con- 
sidered as  such).  Lapersonne  (Le  Bull. 
Med.,  Feb.  21,  '92). 

Three  cases  of  iritis  hsemorrhagica,  in 
which  the  anterior  chamber  was  filled 
with  blood,  which  was  finally  totally 
absorbed.  In  all  three  there  was  a  dis- 
tinct rheumatic  history.  Reche  (Zehen- 
der's  klin.  Monats.  f.  Augenh.,  May,  '92). 

Case  of  recurrent  iritis  occurring  in  a 
young  woman  who  was  subject  to  attacks 
of  subacute  .rheumatism.  The  ocular 
symptoms  yielded  to  salicylic  acid.  Foltz 
(Chicago  Med.  Times,  Dec,  '93). 

Literature  of  '96-'97-'98. 

Of  670  cases  of  iritis  seen,  but  1  was 
rheumatic  in  nature.  (Calcutta  Ophthal- 
mic Hospital  Reports;  Centralb.  f.  prakt. 
Augenh.,  Apr.,  '96.) 

The  flattening  of  the  cornea  against 
the  iris  by  too  firm  pressure  may  set  up 
iritis.  Joeqs  (Le  Bull.  Med.,  Mar.  S,  '96). 

Most  forms  of  iridocyclitis  result  from 
the  action  of  micro-organisms.  Sydney 
Stephenson  (Lancet,  Feb.  29,  '96). 

Most  inflammatory  affections  of  the  iris 
and  ciliary  body  are  the  outcome  of  con- 
si  il  ul  ional  ailments,  which  are  in  turn 
due  to  microbic  infection.  In  certain 
forms  of  iridocyclitis  specific  micro- 
organisms have  been  found  in  the  an- 
terior chamber.  There  exist  good  grounds 
for  believing  the  proximate  cause  of  all 
cases  of  endogenous  iridocyclitis  to  be  the 
excretion  by  the  ciliary  body  of  micro- 


organisms or  their  products.  Therefore 
bacteriological  examination  of  the  aque- 
ous humor  might  furnish  a  ready  means 
of  detecting  an  organism  in  those  mala- 
dies thought  to  be  of  infectious  nature, 
such  as  rheumatism.  It  might  also  lead 
to  a  correct  conclusion  as  to  the  cause  of 
doubtful  cases  of  iridocyclitis.  Stephen- 
son (Lancet,  Feb.  29,  '96). 

Diagnosis. — Iritis  and  cyclitis  nearly 
always  co-exist.  Iritis  may  be  considered 
absent  if  there  is  no  visible  alteration  of 
the  iris  and  the  pupil  dilates  widely  and 
evenly  under  a  mydriatic.  Cyclitis  is  ab- 
sent if  there  be  no  deposit  on  the  cornea, 
or  haziness  of  the  vitreous,  or  tenderness 
of  the  ciliary  region.  Iritis  and  cyclitis 
must  be  distinguished  from  keratitis  by 
absence  of  change  in  the  cornea;  from 
glaucoma  of  the  contracted  pupil,  and 
the  absence  of  dilated  scleral  veins,  in- 
creased tension  or  cupping  of  the  optic 
disk;  from  panophthalmitis  by  the  ab- 
sence of  swelling  of  the  lids  and  dense 
opacity  of  the  vitreous;  from  neuralgia 
by  the  redness  of  the  eye  and  the  altera- 
tion of  the  iris;  from  conjunctivitis  by 
the  slight  swelling  and  freedom  from 
discharge  of  the  conjunctiva.  The  alter- 
ations in  the  pupil  are  best  seen  with 
the  ophthalmoscope  or  after  the  use  of  a 
mydriatic. 

Study  of  the  manifestations  of  syphilis 
in  the  ciliary  body.  Conclusions:  1.  When- 
ever syphilitic  iritis  is  accompanied  by  a 
punctate  keratitis,  either  chronic  or  re- 
cent, areas  of  atrophic  choroiditis  will  be 
found  in  the  ora  serrata.  2.  In  paren- 
chymatous interstitial  keratitis,  when 
due  to  hereditary  syphilis,  disseminated 
plaques,  which  sometimes  reach  to  the 
posterior  segment,  are  seen  in  the  ora 
serrata  ;  more  often,  however,  they  are 
confined  t<>  the  ciliary  region.  3.  Diffuse 
syphilitic  choroiditis  with  disease  of  the 
vitreous  always  presents  atrophic  alter- 
ations of  the  ora  serrata.  and  the  opaci- 
ties of  that  humor  are  due  to  this  latter 
lesion.  4.  In  ataxic  atrophy  of  the  disks 
atrophic  and  pigment  changes  occur  in 


IRITIS;  CYCLITIS;  IRIDOCYCLITIS. 


209 


the  ora  serrata.  5.  In  syphilitic  inflam- 
mation of  the  cerebral  or  cerebro-spinal 
nerves  characteristic  signs  of  the  disease 
appear  in  the  ora  serrata.  Galezowski 
(Gazette  des  Hop.,  Apr.  18,  '94). 

1.  It  is  important,  from  a  clinical  point 
of  view,  to  differentiate  a  tubercular 
variety  of  iritis.  2.  This  form  of  inflam- 
mation is  premonitory  of  the  tubercular 
nodular  eruption,  which  it  may  precede 
by  several  weeks.  3.  It  is  characterized 
by  its  subacute  mode  of  invasion;  its 
evolution  is  slow  and  torpid,  being 
marked  by  faint  reactional  signs,  al- 
though in  addition  there  may  be  dense 
synechia?  more  or  less  completely  ob- 
structing the  pupil.  4.  The  absence  of 
pathognomonic  symptoms  renders  the 
diagnosis  difficult.  5.  The  tendency  to 
spontaneous  cure  of  miliary  tuberculosis 
of  the  iris  depends  upon  the  individual 
resistance,  and  especially  upon  the  resist- 
ance of  the  iris.  The  incapsulation  of 
tubercle  of  the  iris  and  the  rapid  obliter- 
ation of  the  surrounding  capillaries  favor 
its  isolation  and  the  protection  of  the 
sound  tissue.  It  is  not  the  attenuation 
of  the  bacillus  nor  of  the  toxins  which 
brings  about  resolution,  but  the  character 
of  the  tissue  which  receives  the  poison. 
Yignes  (Recueil  d'Ophtal.,  Apr.,  '94). 

Microscopical  study  of  an  eye  with 
supposed  tubercular  iritis,  in  a  girl,  15 
years  of  age,  without  definite  tubercular 
history.  The  affection  began  as  a  brown 
spot  at  the  base  of  the  iris  and  was  fol- 
lowed by  the  appearance  of  other  similar 
areas,  and,  later,  by  blindness.  The 
growth  consisted  of  a  granulomatous- 
looking  mass  (with  a  few  ill-defined 
giant-cells)  situated  near  the  base  of  the 
iris  and  blocking  the  angle  of  the  anterior 
chamber.  Benson  (Dublin  Jour.  Med. 
Science,  Jan.,  '95) . 

Literature  of  '96-'97-'98. 

Painless  iritis,  easily  mistaken  for  less 
serious  diseases,  and  readily  diagnosed 
by  the  instillation  of  a  mydriatic,  is  an 
insidious  and  dangerous  affection,  be- 
cause not  brought  to  the  notice  of  the 
oculist  until  late  in  the  disease,  when 
synechise  have  formed.  G.  Walker 
(Phila.  Polyclinic,  Jan.  9,  '97). 

Importance  of  clearly  separating  from 

4- 


iritis  of  the  ordinary  type  certain  cases 
hitherto  classified  with  it,  but  in  which 
only  the  posterior  layer  of  the  iris,  the 
uvea,  is  involved.  These  cases  grouped 
under  the  term  "uveitis."  The  two  affec- 
tions differ  in  all  respects  as  to  symp- 
toms, course,  causes,  and  cure. 

Uveitis  is  observed  exclusively  among 
women;  iritis 'is  more  frequent  among 
men.  Uveitis  always  affects  both  eyes; 
iritis  often  affects  but  one.  Uveitis  lasts 
for  years,  and  is  manifested  by  slight 
periodical  exacerbations,  lasting  five  or 
six  days;  iritis  is  far  more  violent  in  its 
manifestations,  but  is  cured  in  a  month 
or  two.  The  usual  causes  of  iritis  are 
syphilis,  rheumatism,  and  gout.  These 
are  not  the  causes  of  uveitis,  whose 
causes  are  unknown.  Atropine  is  of  great 
value  in  the  local  treatment  of  iritis ;  but 
iridectomy  is  the  only  effective  local 
treatment  for  uveitis. 

The  differential  diagnosis  during  the 
attack  may  be  made  by  noting  that  in 
iritis  there  is  always  marked  discolora- 
tion of  the  anterior  surface  of  the  iris, 
which  in  uveitis  is  not  perceptible.  In 
iritis  the  pain  and  hypersemia  are  violent  ; 
in  uveitis  pain  is  almost  or  quite  absent 
and  hypersemia  slight.  In  iritis,  even 
apart  from  adhesions,  the  pupil  dilates 
imperfectly  with  atropine;  in  uveitis  it 
dilates  freely,  except  in  so  far  as  it  is 
bound  down  by  old  synechise.  Grand- 
clement  (Lyon  Med.,  torn,  xxxii,  No.  34). 

Prognosis  and  Sequels. — Iritis  is  a 
slow,  painful,  disease  dangerous  to  the 
future  usefulness  of  the  eye.  Eyes  that 
do  well  may  take  many  weeks  to  recover; 
and  pain  may  continue  or  increase  many 
days  after  efficient  treatment  is  begun. 
It  is  liable  to  relapse  or  recur,  especially 
in  rheumatic  or  cachectic  patients.  When 
the  whole  margin  of  the  pupil  is  bound 
clown  to  the  lens,  exclusion  of  the  pupil, 
the  forward  current  of  fluid  from  the 
posterior  chamber  is  obstructed,  pushes 
forward  the  iris,  and  causes  secondary 
glaucoma.  Extensive  plastic  deposits 
about  the  lens  and  in  the  vitreous  are  fol- 
lowed by  softening  and  shrinking  of  the 
eyeball  with  detachment  of  the  retina, 

14 


210 


IRITIS;  CYCLITIS;  IRIDOCYCLITIS. 


blindness,  and  degenerative  changes  in 
all  parts  of  the  eye.    Few  cases  of  iritis 
recover  absolutely,  although  many  eyes 
remain  quiet  and  useful  throughout  life. 
In  New  Orleans  cases  of  iritis  are  of 
much  shorter  duration  (average  of  eight 
cases  12.6  days)   than  at  other  places 
where  the  relative  humidity  of  the  at- 
mosphere is  greater.    Ayres   (New  Or- 


leans Med.  and  Surg.  Jour.,  Au^ 


"8S 


The  only  case  in  ophthalmic  literature 
of  vascular  formation  of  the  lens-capsule 
during  chronic  iritis.  The  iris  had  been 
the  subject  of  repeated  attacks  of  inflam- 
mation leading  to  extensive  synechia?. 
The  new  veins  and  arteries  were  .dis- 
tinctly seen  ramifying  on  the  lower  outer 
section  of  the  capsule.  Darier  (Ann. 
d'Ocul.,  Jan.,  '95). 

Literature  of  '96-'97-'98. 

Corneal  complications  occuring  in  the 
course  of  or  after  plastic  iritis:  fine 
dust-like  deposits  upon  the  membrane  of 
Descemet,  large  deposits  similarly  lo- 
cated (Descematitis),  linear  infiltration 
of  the  substantia  propria,  at  times  as- 
suming the  appearance  of  circumscribed 
sclerotizing  keratitis,  and  in  one  case  re- 
sembling keratitis  punctata  vera.  Frie- 
denwald  (Arch.  Otol.,  Apr.,  '96). 

Serous  iritis  never  exists  without  coin- 
cident cyclitis  and  choroiditis,  and  some- 
times hyalitis.  W.  Cheatham  (Ophth. 
Rec,  Aug.,  '97). 

Sometimes  iritis  causes  a  myopia  that 
may  last  for  some  months. 

Teeatment.  —  The  eye  should  be 
promptly  put  under  the  influence  of  a 
mydriatic,  preferably  atropine,  which 
should  be  continued  until  the  eye  is  free 
from  redness,  except,  in  a  few  cases  of 
cyclitis  without  iritis,  which  do  better 
with  the  pupil  undilated.  The  preven- 
tion and  breaking  up  of  synechias  by  such 
a  drug  is  usually  of  greatesl  importance. 
The  eyes  should  be  given  complete  rest, 
and  protected  from  sudden  changes  of 
light.  Dark  glasses  may  be  worn  in  the 
sunlight.  The  general  nutrition  of  the 
patient  is  so  important  that  confinement 


to  a  dark  room  should  not  be  continued 
more  than  a  few  days.  Pain  may  be  re- 
lieved by  bathing  the  eye  with  very  hot 
water  from  three  to  five  minutes  several 
times  a  day;  or  by  taking  blood  from  the 
temple. 

Scopolamine  hydrobromate  acts  very 
energetically,  often  removing  synechia? 
which  atropine  had  failed  to  influence. 
Quickly  removes  pain  of  iritis  and  other 
inflammations  of  the  anterior  portion  of 
the  eyeball;  scarcely  any  unpleasant 
by-effects.  One  to  2  per  1000  strong 
enough  for  ordinary  purposes.  Repeat 
instillations  three  or  four  times  a  day. 
Raehlmann  (Wiener  med.  Woeh.,  No.  20, 
'94). 

Literature  of  '96-'97-'98. 

Hydrobromate  of  scopolamine  is  of  the 
greatest  value  in  the  local  treatment  of 
the  various  forms  of  plastic  iritis. 

For  quick  and  active  measures,  which 
are  so  eminently  necessary  in  incipient 
cases  of  plastic  iritis,  and  during  the 
early  stages  of  inflammatory  reaction,  the 
scopolamine  salt  is  to  be  preferred  to  the 
atropine ;  but  where  prolonged  use  of 
such  drugs  is  necessary,  as  in  many  cases 
of  the  chronic  form  of  the  disease  with 
subacute  exacerbations,  the  alternate 
employment  of  scopolamine  and  atropine 
seems  empirically  to  be  the  best  method 
of  local  administration  that  has  been  de- 
vised. 

The  best  method  of  instillation  is  by 
dropping  the  solution  upon  the  upper 
corneal  border  while  the  lower  punetnm 
is  everted  and  the  corresponding  canalic- 
ulus is  pressed  upon;  and  the  most 
efficient  amount  to  be  used  at  one  sitting 
is  2  drops  of  a  l/10  of  l-per-cent.  strength 
(1  to  500).  repeated,  if  necessary,  as  often 
as  three  times  during  the  course  of  an 
hour,  and  preceded,  when  desired,  as  in 
some  instances  where  there  are  much  irri- 
tation and  pain,  by  2  drops  of  a  2-per- 
cent, solution  of  hydrobromate  of  cocaine 
a  few  minutes  before  each  instillation  of 
the  scopolamine.  Oliver  (Amer.  Jour. 
Med.  Sciences,  Nov..  "98). 

The  chief  treatment  of  iritis  is  the  use 
of  atropine,  which  should  be  administered 
both   early   and   late,  and   in  sufficient 


IRITIS;  CYCLITIS;  IRIDOCYCLITIS.  IRIDECTOMY. 


211 


strength  to  dilate  the  pupil  thoroughly, 
and  at  such  frequent  intervals  as  to  main- 
tain the  dilatation.  In  the  early  stages 
the  use  of  a  solution  of  4  grains  to  the 
ounce  of  the  sulphate  of  atropine  applied 
every  four  hours,  or  even  more  fre- 
quently, is  necessary  to  bring  about  this 
result.  Good  effects  from  combining 
cocaine  with  the  atropine  in  the  earlier 
stages.  After  full  dilatation  has  been  ob- 
tained the  cocaine  may  be  dropped,  but 
the  use  of  atropine  until  all  inflammation 
of  the  iris  has  disappeared  is  absolutely 
imperative.  L.  F.  Love  (Med.  News,  Jan. 
9,  '97). 

Moist  applications  usually  possess  more 
intensity  of  action  and  are  generally 
used,  though  dry  heat  may  be  more  satis- 
factory in  scleritis  and  iritis.  W.  H. 
Poole  (Jour,  of  the  Amer.  Med.  Assoc., 
May  14,  '98). 

Internally  calomel  should  be  given 
until  the  bowels  are  freely  moved;  and 
mercury  continued  by  inunction  or  in 
other  forms  in  the  syphilitic  cases. 
Whatever  constitutional  condition  is 
present  is  to  be  carefully  treated;  and 
tonics  used  to  build  up  the  general  con- 
dition. 

Three  cases  of  obstinate  iritis  which 
yielded  to  treatment  after  the  correction 
of  different  nasal  conditions.  Septic  sub- 
stances from  the  nose  and  its  adjoining 
cavities  reach  the  uveal  tract  of  the  eye 
either  through  the  lymphatics  or  through 
the  blood.  Ziem  (Annales  des  Mai.  de 
l'Oreille,  du  Larynx,  etc.,  '93). 

Continuous  current  employed  in  eight 
cases  of  old  iritis  complicated  by  syne- 
chia©, currents  weaker  than  5  milliam- 
peres  giving  the  most  favorable  results. 
The  positive  pole  is  placed  behind  the 
ear,  while  the  negative  one  is  applied 
upon  the  closed  eye.  Atropine  is  instilled 
at  each  stance,  which  should  be  about 
twenty-five  minutes  in  length.  The 
amelioration  in  vision  produced  by  this 
plan  of  treatment  is  obtained  (1)  by 
bringing  about  partial  or  complete  ab- 
sorption of  the  exudates  which  block  up 
the  pupil;  (2)  by  clearing  up  the  vitre- 
ous. Bansier  (Annales  d'Ocul.,  Sept., 
'94). 


Analysis  of  105  personal  cases.  Acute 
plastic  iritis,  whether  specific  or  not,  is 
a  self-limited  disease;  while  local  treat- 
ment is  of  the  greatest  value  in  soothing 
the  pain  and  preventing  adhesions,  con- 
stitutional treatment  will  not  tend  to 
shorten  the  duration  of  the  disease. 
Brans  (Med.  News,  July  20,  '95). 

Literature  of  '96-'97-'98. 

Marmorek's  serum  in  small  and  re- 
peated doses  (V2  a  cubic  centimetre  daily 
at  first,  rising  to  1  cubic  centimetre  or 
more)  seems  to  arrest  the  rheumatic 
process  after  one  of  the  three  to  six  suc- 
cessive advances  which  together  consti- 
tute acute  rheumatic  iritis.  In  chronic 
and  long-standing  rheumatic  iritis  with 
organized  adhesions,  sclerosis,  or  atrophy 
of  the  iris,  the  normal  course  of  cyclical 
evolution  does  not  occur,  and  the  influ- 
ence of  any  therapeutic  agent  is,  there- 
fore, less  easy  of  demonstration.  In  cases 
of  relapsing  acute  or  chronic  iritis,  the 
serum  produces  some  amelioration  of  the 
visual  function.  Boucheron  (Gaz.  Heb- 
dom.  de  Med.  et  de  Chir.,  June  16,  '98). 

Case  of  violent  iridocyclitis  in  a  man 
who  had  general  ciliary  injection,  con- 
tracted pupils,  extensive  posterior  syne- 
chias, and  deposits  on  the  posterior  sur- 
face of  the  cornea.  T.  +  1.  V.  R.  6/G0, 
L.  V24.  After  twenty-one  hypodermic  in- 
jections of  Vs  grain  of  pilocarpine  muri- 
ate, extending  over  seven  weeks,  and  60 
grains  of  potassium  iodide  daily  with 
mercury  occasionally,  improvement  was 
rapid  and  pronounced.  V.  increased  to 
R.  6/24,  L.  6/15.  There  were  no  relapses, 
tension  became  normal,  and  the  exuda- 
tion was  promptly  absorbed.  Six  months 
later  V.  had  increased  to  R.  %,  L.  % 
with  —50°,  Ax.  90°.  R.  R.  Tybout 
(Columbus  Med.  Jour.,  Dec.  20,  '98). 

Iridectomy. — The  excision  of  a  part  of 
the  iris  may  he  required  for  the  sequels 
of  iritis,  as  exclusion  of  the  pupil  or  ex- 
tensive synechia;  for  occlusion  of  the 
pupil,  its  closure  by  a  deposit  of  lymph; 
for  corneal  opacity  in  front  of  the  pupil, 
some  part  of  the  cornea  remaining  clear; 
for  partial  opacity  of  the  lens;  or  for 
glaucoma. 


212 


IRITIS;  CYCLITLS;  IRIDOCYCLITIS.  IRIDECTOMY. 


Location. — If  done  to  secure  a  clear 
passage  for  light  through  the  dioptric 
media,  "optical  iridectomy/'  it  must  be 
located  so  light  can  enter  through  the 
best  dioptric  surfaces,  must  be  as  small 
as  will  remain  subsequently  unobstructed 
and  must  be  exposed  when  the  lids  are 
opened.  If  it  is  merely  to  free  the  iris 
from  its  adhesions,  or  open  up  a  passage 
from  the  posterior  to  the  anterior  cham- 
ber, or  for  glaucoma,  it  should  be  placed 
where  it  will  ordinarily  be  hidden  as 
much  as  possible  beneath  the  lids.  For 
glaucoma  it  should  be  large,  including 
one-fifth  of  the  circumference  of  the  iris, 
and  should  extend  up  to  the  ciliary  mar- 
gin. 

Technique. — An  incision  is  made  in  the 
cornea  between  the  location  for  the  iri- 
dectomy and  the  corneal  margin,  slightly 
longer  than  the  width  of  the  iridectomy 
and  parallel  to  the  corneal  margin.  This 
is  made  either  with  a  narrow  Graefe  knife 
or  a  lance-shaped  keratome.  A  pair  of 
iris-forceps  is  introduced  and  the  iris 
seized  near  its  pupillary  margin,  and  the 
part  so  caught  is  drawn  outside  the  cor- 
neal incision.  Sometimes  the  iris  can 
be  better  separated  from  adhesions  by  a 
blunt  iris-hook  which  is  pressed  upon  the  i 
pupillary  edge  of  the  iris  until  it  catches 
under  it,  and  draws  it  out  through  the 
corneal  incision.  A  sufficient  portion  of 
the  iris  having  been  drawn  out,  it  is  cut 
off  with  fine  scissors,  the  stump  is  re- 
turned within  the  eye,  care  being  taken 
to  free  it  entirely  from  the  corneal  in- 
cision; and  the  eye  is  closed  with  a  light 
dressing  until  the  corneal  wound  ceases 
to  allow  the  escape  of  the  aqueous, 
usually  but  a  few  hours.  Iridectomy 
should  not  be  done  for  the  sequela?  of 
iritis  until  long  after  the  eye  has  become 
free  from  redness  or  irritability. 

In  iridectomy  instead  of  drawing  the 
iris  out  and  stretching-   (perhaps  tear- 


ing) the  fibres,  so  that  the  resultant 
coloboma  is  irregular  and  misplaced,  two 
incisions  four  to  five  millimetres  wide, 
one  above  and  the  other  below,  should  be 
made.  The  de  Wecker  scissor-forceps  are 
then  introduced  into  the  lower  section, 
and  the  pointed  branch  is  slipped  beneath 
the  iris.  Incisions  are  now  made  to  the 
right  and  the  left,  thus  circumscribing 
the  summit  of  a  triangle.  The  forceps 
are  now  introduced  from  above,  the  flap 
is  withdrawn  and  is  cut  squarely  off  by 
a  third  snip.  In  this  way  a  large,  gaping 
opening  is  formed,  with  the  apex  of  the 
triangle  directed  downward.  Abadie 
(Annales  d'Ocul.,  June,  '88). 

The  following  operation  devised  for  the 
treatment  of  iridodialysis  from  contu- 
sion: "A  narrow,  somewhat  slanting  in- 
cision was  made  in  the  cornea,  near  the 
sclero-corneal  junction,  with  a  broad 
needle  or  a  very  small  keratome.  Fine 
forceps  are  introduced,  and  the  iris,  near 
its  detached  periphery,  is  seized  and 
drawn  into  the  wound.  A  small  portion 
is  drawn  through  the  wound,  enough  only 
to  insure  being  held  in  position  by  a 
compress  bandage,  till  healing  has  taken 
place.  In  order  to  more  thoroughly  se- 
cure its  maintenance  in  the  wound,  a 
fine  suture  may  be  passed  through  the 
conjunctiva  at  the  border  of  the  wound, 
and  the  iris  stitched  thereto.  The  suture 
may  be  removed  in  forty-eight  hours.'' 
Operation  successfully  performed  in  four 
cases.  E.  Smith  (Jour.  Amer.  Med. 
Assoc.,  Sept.  19,  "91). 

Case  of  syphilitic  iritis  with  gum- 
matous formations  in  both  irides,  in 
which  iridectomy  was  successfully  per- 
formed after  the  iris-tissue  had  become 
atrophic.  Myers  (Va.  Med.  Monthly. 
June.  "93). 

In  anterior  synechia*  the  synechia*  are 
cut  through  by  means  of  a  special  blunt- 
pointed  knife,  the  blade  of  which  is 
curved  to  represent  the  third  of  a  cir- 
cumference and  having  a  diameter  of 
seven  to  eight  millimetres.  An  opening 
less  than  one  millimetre  long  is  made  in 
the  cornea  with  a  Graefe  cataract-knife, 
parallel  to  the  radiating  fibres  of  the  iris, 
care  being  taken  to  avoid  wounding  the 
iris  and  the  lens.  The  synechotome  is 
then  introduced  between  the  cornea  and 


IRIS,  CILIARY  BODY,  AND 


CHOROID.  CHOROIDITIS. 


213 


the  synechia?  and  the  latter  are  cut 
through  by  traction  with  the  curved 
knife.  Atropine  and  bandage  complete 
the  operation.  The  following  are  neces- 
sary conditions  for  the  operation:  1.  The 
synechia?  ought  to  be  sufficiently  central, 
that  the  knife  may  pass  between  the 
point  of  attachment  of  the  iris  and  its 
great  circle.  2.  At  the  point  chosen  for 
the  puncture  of  the  cornea  the  anterior 
chamber  must  be  deep  enough  to  prevent 
a  wounding  of  the  iris  or  to  produce  an 
adhesion  in  this  place.  Gaupillat  (Re- 
cueil  d'Ophtal.,  June,  '95). 

Literature  of  '96-'97-'98. 

In  order  to  avoid  prolapse  of  the  vitre- 
ous in  iridotomy  or  iridectomy  for  occlu- 
sion of  the  pupil,  a  narrow  knife  should 
be  introduced  through  the  corneo-scleral 
junction  and  the  iris  incised  before  the 
counter-puncture  is  made  in  the  limbus 
on  the  opposite  side.  Segal  (Novotschen- 
Kask,  Yestnik  of  Ophth.,  Jan.,  Feb.,  '96). 

Choroiditis. 

Plastic  inflammation  and  atkophy 
of  the  choeoid  is  more  of  a  chronic  de- 
generative process  than  an  acute  inflam- 
mation. It  often  accompanies  similar  in- 
flammation of  the  iris  and  ciliary  body, 
and  is  variously  designated  "choroiditis/7 
"iridochoroiditis,"  and  "choroidal  at- 
rophy/7 

Symptoms. — Only  the  appearances  re- 
vealed by  the  ophthalmoscope  are  char- 
acteristic of  this  disease,  although  it  may 
be  attended  with  discomfort  or  aching  in 
and  about  the  eyes,  flashes  of  light,  im- 
pairment of  vision  by  scotomata,  or 
clouds  due  to  vitreous  opacities.  In  the 
early  stages  of  exudation  the  choroid  may 
be  swelled,  is  lighter  color,  yellower  than 
normal;  and  may  be  veiled  by  haziness 
of  the  vitreous;  but  there  are  no  pigment 
deposits.  Later,  as  the  process  passes  on 
to  atrophy,  the  margins  and  parts  in- 
cluded in  the  affected  area  show  brown 
or  black  pigment  deposits,  between  which 
may  be  seen  the  large  vessels  of  the  deep 


|  layer  of  the  choroid  or  the  white  sclera. 
Throughout  the  disease  the  retinal  ves- 
sels run  over  the  affected  area  undis- 
turbed. When  the  atrophy  and  pigment 
deposits  are  complete,  the  appearances 
produced  tend  to  continue  throughout 
life. 

Etiology. — The  causes  of  inflamma- 
tion of  the  iris  and  ciliary  body  similarly 
affect  the  choroid.  In  addition,  it  is 
liable  to  suffer  from  eye-strain  in  hyper- 
opia, astigmatism,  and  most  extensively 
in  myopia.  Excessive  use  of  the  eyes 
and  exposure  to  excessive  light  and  heat, 
especially  when  habitually  concentrated 
on  one  part  of  the  choroid,  are  also  im- 
portant causes. 

Two  cases  of  gonorrhoea!  iridochoroi- 
ditis.  In  one  instance  the  attack  mani- 
fested itself  on  the  eighth  day,  and  in 
the  second  upon  the  fourth  day  after  the 
appearance  of  the  urethral  discharge, 
subsequent  to  the  occurrence  of  an  arthri- 
tis. Both  cases  made  good  recoveries 
under  the  administration  of  large  doses 
of  salicylate  of  sodium  and  cinchonidia, 
potassium  iodide,  and  appropriate  local 
treatment.  Bull  (Annals  of  Ophth.  and 
Otol.,  Apr.,  '93). 

In  specific  retinochoroiclitis  the  choroid 
is  primarily  affected,  the  retina  sec- 
ondarily, because  the  retinal  lesions  are 
limited  to  the  foveal  region,  while  those 
in  the  choroid  are  more  disseminated. 
Rochon  -  Duvignaud  (Arch.  d'Ophtal., 
Dec,  '95). 

Literature  of  '96-'97-'98. 

Two  cases  of  suppurative  iridochoroi- 
ditis  caused  by  autoinfection.  The  first 
was  seen  in  a  man  convalescent  from 
broncho  -  pneumonia,  accompanied  by 
arthritis  of  the  shoulder.  The  second 
was  of  puerperal  origin  and  was  associ- 
ated with  phlegmasia  alba  dolens.  In 
both  instances  there  was  absence  of  pain. 
Despagnet  (Kecueil  d'Ophtal.,  Sept.,  '96). 

Case  of  double  chorioretinitis  in  the 
macular  regions,  following  a  flash  of 
lightning  and  a  flash  from  burning  lyco- 
podium.    The  patient,  a  man  21  years  of 


2U 


IRIS,  CILIARY  BODY,  AND  CHOROID.  CHOROIDITIS. 


age,  was  stunned  by  a  stroke  of  light- 
ning and  upon  recovering  was  unable  to 
see  for  several  moments,  the  sight  return- 
ing first  in  the  right  eye.  Later  in  the 
same  day  he  was  exposed  to  a  flash  of 
lycopodium  powder.  The  following  day 
he  noticed  scintillating  scotomata,  which 
persisted  in  greatly  varying  forms,  to- 
gether with  micropsia  in  the  right  eye. 
In  the  same  eye,  directly  in  the  macular 
region,  the  retinal  tissue  seemed  to  be 
slightly  puffed  into  an  irregular  flattened 
mass.  The  tissue  itself  did  not  appear 
to  be  opaque  or  discolored,  but  glistened 
in  places  as  though  the  underlying  ma- 
terial was  composed  of  an  extremely-thin 
coating  of  cicatrizing,  almost  transparent 
jelly.  In  both  eyes  the  nerve-head  was  a 
trifle  gray  and  hazy.  The  left  eye  was 
similarly  affected,  though  to  a  less  de- 
gree. The  visual  fields  were  normal  in 
extent,  but  exhibited  a  series  of  relative 
scotomata.  Three  months  later  a  small 
haemorrhage  was  visible  between  the 
choroid  and  retina  below  the  left  fovea. 
The  patient  made  almost  full  recovery. 
Oliver  (Internat.  Med.  Mag..  Oct.,  '96). 

Conclusions  based  on  a  study  of  met- 
astatic choroiditis :  — 

1.  Metastatic  choroiditis,  or  suppura- 
tive panophthalmitis,  may  follow  septic 
infection  through  the  genital  tract  after 
labor. 

2.  As  a  rule,  both  eyes  are  affected, 
although  one  alone  may  be  affected. 

3.  The  disease  first  commences  in  the 
uveal  tract,  afterward  involves  the  vitre- 
ous humor,  and  finally  is  exhibited  in 
great  swelling  of  the  lids,  with  chemosis 
of  the  conjunctiva,  and,  usually,  rupture 
of  the  cornea  or  sclera,  or  both. 

4.  The  prognosis  for  sight  is  bad  in  all 
cases. 

5.  The  prognosis  for  life  is  worse  when 
the  disease  is  bilateral  than  when  it  is 
unilateral,  and  is  bad  in  all  cases. 

(5.  Endocarditis  is  present  in  the  ma- 
jority of  cases. 

7.  Surgical  interference  is  distinctly 
contra-indicated.  J.  Herbert  Claiborne 
(Annals  of  Ophth.,  Apr..  '5)7). 

Five  cases  of  choroiditis  in  young  pa- 
tients caused  by  excessive  functional  ac- 
tivity of  the  eyes.  Diminished  tonicity 
of  the  tissues  and  circulation  incident  to 
in-door  work,  vitiated  air.  want  of  sun- 


light, lack  of  exercise,  and  indulgence  in 
improper  focd.  A.  C.  Corr  (Amer.  Jour, 
of  Ophthal.,  July,  '98). 

Varieties. — When  one  or  two  large 

areas  of  the  choroid  are  affected  at  once 
it  is  called  diffuse  choroiditis.  When 
small  areas  are  affected  the  remainder  of 
the  choroid  being  normal,  it  is  called 
localized  choroiditis  if  only  one  or  two 
patches  appear,  or  disseminated  choroi- 
ditis if  there  are  several.  When  the  re- 
gion of  the  macula  is  involved  it  is  called 
central  choroiditis;  and  a  form  of  the 
central  occurring  in  old  persons  is  called 
senile. 

Senile  chorioretinitis  of  macular  re- 
gion; entire  fundus  dotted  with  many 
yellowish-gray,  round  spots;  larger  ones 
in  macular  region.  Wiegmann  (Zehen- 
der's  klin.  Monats.  f.  Augenh.,  Nov.,  '94). 

Diagnosis. — Choroiditis  is  recognized 
with  the  ophthalmoscope  by  the  color 
and  pigmentation  of  the  affected  areas. 
It  has  to  be  distinguished  from  exudation 
I  or  opaque  nerve-fibres  in  the  retina  and 
from  coloboma  of  the  choroid. 

Tuberculosis  of  the  choroid  is  to  be 
distinguished  from  glioma  of  the  retina 
by  the  early  appearance  of  inflammatory 
symptoms,  including  iritis:  phenomena 
which  are  wanting  in  this  stage  in  glioma. 
Wagenmann  (Deutsche  med.  YVoch.,  Oct. 
1,  '91). 

Prognosis. — Choroidal  inflammation 
is  always  serious.  Its  obscure,  persistent 
causes,  difficult  of  recognition  and  re- 
moval, make  it  generally  a  disease  liable 
to  continue  until  it  has  done  very  grave 
I  damage  to  the  eye.  It  is  worth  every 
effort  to  permanently  check  its  progress. 
Cases  where  it  is  localized  and  does  not 
involve  the  macula  are  the  most  favor- 
able, and  may  end  in  cure  without  notice- 
able impairment  of  vision. 

Treatment.  —  Complete  rest  for  the 
eyes,  often  under  a  mydriatic,  is  im- 
portant, with  protection  from  >udden 
changes  or  great  excess  of  light,  or  ex- 


IRIS,  CILIARY  BODY,  AND  CHOROID. 


PURULENT  INFLAMMATION.  215 


posure  to  heat.    This  will  sometimes  re- 
quire a  change  of  occupation,  as  the  giv- 
ing up  of  cooking  or  blacksmithing. 
Correcting  lenses  must  be  constantly 
worn,  and  during  the  acute  stage  much 
use  of  near  vision  should  he  avoided. 
The  underlying  dyscrasia  must  also  re- 
ceive efficient  treatment,  for  upon  this 
will  depend  the  persistence  and  extension 
of  the  disease  and  the  ultimate  results. 
Syphilis  should  be  combated  by  the  pro- 
longed use  of  mercury;  with,  sometimes, 
iodides  late  in  the  disease.    A  general 
tonic  regimen  is  generally  required.  Out- 
door life  is  beneficial,  and  on  account  of 
its  depressing  influence  upon  general 
nutrition  prolonged  confinement  to  a 
dark  room  should  be  carefully  avoided. 
Improvement  obtained  in  a  case  of 
specific  choroiditis  by  the  application  of 
mercurial  inunction.    The  patient  had  a 
marked  intolerance  for  potassium  iodide 
and  the  bichloride  of  mercury.  Micleso 
(Bull,  de  la  Soc.  des  Med.  et  Nat.  de 
Jassy,  '92). 

An  instance  of  acute,  central,  exudative 
chorioretinitis  in  which  sight  rapidly  im- 
proved upon  the  subconjunctival  injec- 
tion of  mercury  after  inunctions  of  the 
same  drug  had  failed.  Scheidemann 
(Centralb.  f.  prak.  Augenh.,  Sept.,  '93). 

Case  of  central  choroiditis,  in  which 
vision  was  nearly  lost,  cured  by  the  use 
of  subconjunctival  injections  of  bichloride 
of  mercury.  Inunctions  of  mercury  and 
the  iodides  had  been  used  without  avail. 
Darier  (Annales  d'Ocul.,  Mar.,  '93). 

Case  of  suppurative  iridochoroiditis; 
recovery  by  subconjunctival  injections  of 
bichloride,  mercurial  inunctions,  and  in- 
jections of  bichloride,  with  atropine  and 
hot  compresses.  Coppez  (Revue  Gen. 
d'Ophtal.,  Sept.  30,  '95). 

Case  of  choroiditis  of  several  months' 
duration  in  which,  notwithstanding  the 
use  of  iodide  of  potassium,  etc.,  vision  was 
reduced  to  light-perception.  Gradual  im- 
provement occurred  under  the  hypoder- 
mic use  of  pilocarpine  in  doses  of  from 
Ve  to  7,  grain.  Fryer  (Kansas  City  Med. 
Index,  '92). 

Case  of  metastatic  exudative  muco-  I 


purulent  chorioretinitis,  with  complica- 
tions following  remittent  fever,  studied  in 
which  the  fellow-eye  showed  symptoms 
of  sympathetic  irritation.  Removal  of 
the  exciting  eye  was  followed  by  com- 
plete recovery  of  the  sympathizing  one. 
Schwartzschild  believes  that  the  sympa- 
thetic affection  was  caused  by  the  trac- 
tion of  the  inflammatory  exudate  upon 
the  ciliary  processes,  and  that  the  disease 
is  a  neurosis  of  reflex  origin.  Weber  and 
Schwartzschild  (Amer.  Jour,  of  Ophthal., 
Apr.,  '93). 

Literature  of  '96-'97-'98. 

Conclusions  regarding  the  treatment  of 
choroiditis:  1.  The  subcutaneous  injec- 
tions of  iodine  are  more  efficacious  than 
other  iodized  preparations  in  the  affec- 
tions of  the  uveal  tract  amenable  to  this 
treatment.  2.  Such  affections  are  dis- 
seminated choroiditis,  fibrinous  irido- 
choroiditis, and  iridosclerochoroiditis. 
In  the  last  two  they  should  be  joined 
with  the  usual  remedies,  particularly 
cauterization.  3.  The  injections  are  es- 
pecially valuable  in  choroiditis  of  rheu- 
matic and  of  bacillary  origin.  4.  In  spe- 
cific forms  they  are  no  better  than 
iodides,  and  are  inferior  to  mercury. 
5.  The  daily  doses  vary  from  0.1  to  0.4 
centigramme;  the  reaction  is  insignifi- 
cant. Vignes  (Archives  d'Ophtal.,  Aug., 
'96). 

Purulent  Inflammation  of  the  Iris, 
Ciliary  Body,  and  Choroid. — Although 
in  grave  plastic  iritis  hypopyon  may  ap- 
pear, the  exudate  becoming  largely  pu- 
rulent, these  cases  running  the  general 
course  of  plastic  iritis  require  no  sepa- 
rate consideration.  A  totally  distinct 
clinical  picture  is  presented  when  general 
suppuration  of  the  uveal  tract  occurs, 
called,  "suppurative  choroiditis,7'  or 
"iridochoroiditis,"  or,  from  its  involve- 
ment of  all  parts  of  the  eye,  "panophthal- 
mitis. 

Symptoms. — The  disease  begins  with 
great  disturbance  of  vision,  pain  in  and 
about  the  eye,  and  general  redness.  The 
conjunctiva,  the  lids,  and  often  the  tis- 


216        IK  IS,  CILIARY  BODY,  AND  CHOROID.    PURULENT  INFLAMMATION. 


sues  of  the  orbit  become  greatly  swelled. 
Haziness  of  the  vitreous  quickly  prevents 
any  view  of  the  fundus;  and  the  eye 
rapidly  becomes  entirely  blind.  The 
pain  continues  to  increase  until  the 
sclero-corneal  coat  is  perforated,  allowing 
exit  to  the  contained  pus.  Then  pain 
rapidly  diminishes,  the  swelling  goes 
down  and  the  eyeball  soon  shrinks  to  a 
small,  sightless,  and  generally  harmless 
stump:  phthisis  tuTbi. 

Etiology. — Suppuration  of  the  uveal 
tract  arises  from  infected  wounds,  either 
accidental  or  operative;  from  perforat- 
ing ulcer  or  abscess  of  the  cornea;  or 
thrombosis  of  the  orbital  veins  in  orbital 
cellulitis.  It  may  also  be  produced  by 
metastasis  or  embolism  in  connection 
with  abscess  in  other  parts  of  the  body,  or 
in  pyaemic  conditions,  puerperal  sepsis, 
or  erysipelas,  or  in  cerebro-spinal  men- 
ingitis, influenza,  scarlatina,  and  other 
acute  specific  fevers. 

Diagnosis. — The  disease  cannot  es- 
cape notice  unless  masked  by  previous 
inflammation  of  the  orbit,  erysipelas  of 
the  lids,  or  suppuration  of  the  cornea;  or 
unless  it  occur  in  the  course  of  exhaust- 
ing disease,  when  the  local  reaction  may 
be  slight,  and  the  loss  of  vision  unnoticed 
by  the  dull  or  unconscious  patient.  It 
is  to  be  distinguished  from  other  ocular 
inflammations,  by  the  opacity  of  the  vit- 
reous and  rapid  loss  of  sight;  or  when  it 
supervenes  upon  corneal  ulcer,  by  in- 
crease of  pain  and  swelling. 

Prognosis. — Most  cases  run  a  rapid 
course  to  complete  blindness  and  phthisis 
bulbi.  In  a  few  the  reaction  is  less  severe 
and  a  purulent  accumulation  in  the  vit- 
reous simulating  in  appearance  glioma  of 
the  retina  remains  indefinitely.  Such 
cases  are  called  "pseudoglioma."  In  a 
very  few  cases  in  children,  where  the 
purulent  choroiditis  follows  specific 
fevers,    and    especially  cerebro-spinal 


meningitis,  some  sight  is  retained,  and 
the  vitreous  humor  may-  subsequently 
clear  up  to  a  considerable  extent. 

Intensely  acute  inflammation  of  the 
whole  uveal  tract  seen  in  both  eyes  of  an 
apparently  perfectly  healthy  child  of  G 
years.  The  onset  resembled  that  of  acute 
glaucoma.  Complete  blindness  was  pro- 
duced in  thirty-six  hours.  Though  the 
exudates  had  been  reabsorbed  in  six 
weeks,  it  was  not  until  fourteen  months 
later  that  vision  was  found  to  be  com- 
pletely restored.  Brandenburg  (Archiv 
f.  Augenh.,  Aug.,  '90). 

Literature  of  '96-'97-'98. 

Case  of  metastatic  iridochoroiditis  end- 
ing in  panophthalmitis  in  a  9-month-old 
infant.  Rupture  of  the  globe  finally  en- 
sued. R.  S.  Randolph  (Ann.  Ophth.  and 
Otol.,  Oct.,  '96). 

Teeatment. — Pain  is  most  promptly 
relieved  and  the  disease  cut  short  by 
enucleation  of  the  eye;  but  this  has  in  a 
few  cases  been  followed  by  death  from 
meningitis.  Some  authors  believe  that 
the  risk  of  meningitis  is  increased  by 
enucleation;  but  this  is  very  doubtful  if 
proper  care  is  taken  to  cleanse  the  wound 
and  secure  free  drainage. 

To  prevent  dissemination  to  the  me- 
ninges, early  operation  is  considered 
essential  in  the  insidious  forms  of  pan- 
ophthalmitis. Du  Gourlay  (Annales 
d'Ocul.,  Oct.,  '92). 

When,  because  of  the  patient's  condi- 
tion or  disinclination,  enucleation  cannot 
be  done,  the  eye  should  be  poulticed, 
and  after  two  or  three  days  opened  by  a 
free  incision  across  the  cornea  that  will 
permit  the  escape  of  the  crystalline  lens 
and  all  purulent  accumulations.  Anal- 
gesics, such  as  morphine  and  acetanilid, 
may  be  necessary  until  the  eye  is  opened. 
If  the  eye  retains  some  sight,  poulticing 
is  improper;  rest,  atropine,  and  bleeding 
from  the  temple  are  indipated.  Even 
where  the  eye  is  blind,  but  the  pain  and 


IRIS,  CILIARY  BODY,  AND  CHOROID.  TUMORS. 


217 


swelling  not  severe,  as  in  pseudoglioma, 
it  may  be  wise  to  defer  operation  until 
the  general  health  is  improved. 

Tumors  of  the  Uveal  Tract. — This  is 
a  not  .very  unusual  seat  of  secondary 
tumors,  although  they  may  attract  little 
attention,  appearing  late  and  growing 
slowly.  The  following  are  the  principal 
primary  new  growths. 

Cyst  of  the  iris  is  apt  to  follow  a 
penetrating  wound  in  which  a  bit  of  epi- 
thelium or  eyelash  has  been  implanted  on 
the  iris.  It  may  have  the  form  of  a  serous 
cyst  occupying  a  large  part  of  the  an- 
terior chamber,  or  an  epithelial  pearl  on 
the  surface  of  the  iris.  Either  form  may 
cause  secondary  glaucoma.  It  should  be 
excised. 

Case  of  idiopathic  cyst  of  the  iris, 
which  throws  more  light  upon  personal 
belief  that  they  are  the  result  of  incapsu- 
lation  of  an  iris-crypt  by  bands  which 
have  become  thickened  and  enlarged  by 
some  pathological  process.  Schmidt- 
Rimpler  (Archiv  f.  Ophthal.  (Grafe), 
Apr.,  '89). 

Cyst  of  the  iris  observed  to  develop 
after  the  performance  of  an  iridectomy, 
with  removal  of  a  cilium  from  the  an- 
terior chamber  and  the  discission  of  a 
secondary  cataract,  in  an  eye  which  had 
been  injured  eleven  years  previously. 
Burnett  (Archives  of  Ophthal.,  Apr.,  '92). 

Case  of  epithelial  pearl-tumor  in  the 
iris  following  the  implantation  of  an  eye- 
lash into  the  anterior  chamber.  When 
first  seen,  seven  months  after  the  injury, 
the  cilium  was  extracted  and  an  un- 
successful attempt  was  made  to  remove 
the  tumor.  One  year  later  the  growth 
had  increased  in  size,  and  the  eye  was 
enucleated  on  account  of  sympathetic 
irritation.  The  tumor,  which  was  sur- 
rounded by  pigmented  iris-tissue,  was 
found  to  be  free  from  the  cornea,  ciliary 
body,  and  vitreous,  and  proved  to  be  a 
cyst  lined  by  laminated  epithelium  and 
containing  an  opaque  white  substance, 
composed  of  fat-globules  and  polyhedral 
cells.  Cross  and  Collins  (Lancet,  July 
15,  '93). 


Literature  of  '96-'97-'98. 

Case  of  uveal  cysts  of  the  iris  in  which 
the  diagnosis  was  made  clinically.  The 
condition  was  seen  in  an  eye  with  abso- 
lute glaucoma  resulting  from  chronic 
non-inflammatory  glaucoma  in  a  man  40 
years  old.  The  masses,  two  in  number, 
extended  into  the  pupillary  space  and 
moved  freely.  The  surface  of  each  was 
jelly-like  and  quivering,  producing  fine 
creases  in  the  cyst-wall.  Microscopical 
examination  corroborated  the  clinical 
diagnosis.  Eales  Birmingham  and  Sin- 
clair Ipswich  (Lancet,  Feb.  15,  '96). 

Iridectomy  advised  for  two  brownish 
tumors  protruding  from  behind  the  outer 
lower  quadrant  of  both  irides.  The 
opinion  given  that  these  are  uveal  cysts, 
not  secondary  to  malignant  neoplasms, 
and  perhaps  arising  from  the  anterior 
border  of  the  ciliary  body.  M.  W.  Zim- 
mermann  (Ann.  of  Ophth.,  July,  '97). 

Gumma  may  develop  in  the  iris,  caus- 
ing one  or  more  rounded  swellings,  at- 
tended with  iritis;  or  in  the  ciliary  body, 
where  it  is  also  attended  with  inflam- 
mation, and  may  cause  ciliary  staphy- 
loma either  from  its  primary  swelling  or 
by  thinning  of  the  overlying  sclera  by 
absorption  so  that  it  cannot  resist  intra- 
ocular pressure.  In  the  iris  it  usually 
leaves  a  thinned  and  atrophied  spot 
through  which  may  in  some  cases  be  seen 
the  fundus-reflex.  Active  antisyphilitic 
treatment  is  indicated. 

Rare  case  observed  of  gummatous  iritis 
the  result  of  hereditary  syphilis,  in  a 
female  child  7  months  old.  The  anterior 
chamber  was  filled  by  an  hemorrhagic 
exudate,  the  iris  being  almost  unrecog- 
nizable. Liebrecht  (Zehender's  klin. 
Monats.  f.  Augenh.,  May,  '91). 

Two  cases  of  syphilitic  gumma  of  the 
ciliary  body.  The  tumor  passed  through 
the  iris  angle  into  the  anterior  chamber 
and  invaded  the  iris,  which  was  also  the 
seat  of  the  usual  condylomata.  In  one 
case  there  was  a  perforation  of  the  sclera 
and  conjunctiva  through  which  the  most 
of  the  broken-down  tumor-mass  was 
evacuated.    Under  treatment  the  results 


218 


IRIS,  CILIARY  BODY,  AND  CHOROID.  SARCOMA. 


in  both  cases  were  good.  Gallenga 
(Annal.  di  Ottal.,  xxv,  2,  3,  p.  210). 

Differential  diagnosis  of  gumma  and 
sarcoma  of  ciliary  region:  first,  early 
iritis,  vitreous  opacities,  perhaps  dimin- 
ished tension,  rapid  evolution,  and  bulg- 
ing of  sclera;  second,  slow  non-inflam- 
matory onset  with  glaucoma  later; 
thorough  therapeutic  test  to  be  made 
before  enucleation.  Rochon-Duvigneaud 
(Revue  Gen.  de  Clin,  et  de  Ther.  Jour, 
des  Prat.,  Apr.  13,  '95). 

Literature  of  '96-'97-'98. 

True  gumma  of  the  ciliary  body  that 
finally  yielded  to  specific  treatment  wit- 
nessed two  and  a  half  years  after  the 
primary  infection.  In  addition  to  the 
signs  of  syphilitic  iritis,  there  was  bulg- 
ing forward  of  the  iris  adjacent  to  the 
tumor,  producing  different  depths  in  the 
anterior  chamber,  gummatous  growths 
in  the  iris,  circumscribed  discoloration 
and  distinction  of  the  sclera  (ciliary 
staphyloma),  and  almost  total  loss  of 
vision  from  exudation  into  the  vitreous 
and  the  pupillary  area.  H.  C.  Highet 
(Brit.  Med.  Jour.,  Nov.  7,  '96). 

Case  of  unilateral  syphilitic  iritis,  with 
typical  gumma,  occurring  in  a  man  25 
years  old,  three  months  after  chancre 
of  the  lip,  and  preceded  by  roseola, 
mucous  patches,  etc.  Cure  was  ap- 
parently obtained  after  a  month's  treat- 
ment, but  a  second  attack  was  precipi- 
tated by  instillation  of  pilocarpine.  The 
inflammation  was  ultimately  cured  with- 
out any  trace  of  the  affection,  vision 
being  absolutely  perfect  six  months  after. 
Armaignac  (Recueil  d'Ophtal.,  Mar.,  '96). 

Three  cases  of  gumma  of  the  ciliary 
body  observed  in  patients  21,  27,  and  26 
years  old.  They  appeared  2  1/z  years,  6 
months,  and  2  years  after  the  initial 
lesion.  One  preserved  a  certain  degree 
of  sight  in  spite  of  scleral  perforation. 
In  the  other  two  the  globe  atrophied. 
Injections  of  calomel  once  a  week  gives 
the  best  results,  but  they  should  be  com- 
bined with  inunctions  and  with  injections 
of  the  soluble  salts  of  mercury  daily. 
Terson  (Archives  d'Ophtal.,  July,  '96). 

Ossification  of  the  choroid  is  often 
found  in  eyeballs  that  have  long  been 


blind,  and  have  undergone  extensive  de- 
generative changes.  It  may  cause  sympa- 
thetic irritation,  but  not  inflammation, 
of  the  fellow-eye. 

Sarcoma  may  arise  primarily  in  either 
part  of  the  uveal  tract.    In  the  iris  it  ap- 

|  pears  as  a  tumor  which  grows  very  slowly, 
usually  brown  and  deeply  pigmented, 

|  sometimes  of  lighter  color,  with  visible 
vessels. 

Case  of  primary  sarcoma  of  the  iris, 
with  secondary  nodes  in  the  choroid. 
The  growth  was  first  noticed  when  the 
patient  was  ten  years  old,  and  was  prob- 
ably congenital.  When  the  patient  was 
fifty-eight  years  old  enucleation  was  per- 
formed, the  growth  having  destroyed  the 
eye.  The  small  melanoma  had  developed 
into  a  sarcoma,  which  had  infiltrated  all 
the  structures  of  the  globe.  From 
twenty-eight  melanotic  tumors  of  the 
iris,  twenty-six  were  found  malignant. 
Whiting  (Archiv  f.  Augenh.,  Mar.,  '92). 

The  differential  diagnosis  with  the 
ophthalmoscope  between  leucosarcoma 
and  melanotic  sarcoma  can  only  be  made 
either  when  the  pigment  of  the  hexagonal 
pigment-layer  is  absent,  as  in  an  albino, 
or  where  this  layer  has  been  broken 
through  by  the  growth.  Hill  Griffith 
(Med.  Chronicle,  May,  '92). 

Literature  of  'd6-'97-'9S. 

(  ase  of  simple  melanoma  of  the  h  i-, 
with  (associated)  symptoms  simulating 
simple  non- inflammatory  glaucoma.  The 
alteration  in  the  color  of  the  left  iris  had 
been  increasing  for  a  period  of  seven 
years  and  had  been  accompanied  by  a 
gradual  loss  of  vision.  The  melanosis 
had  partly  saturated  the  sclera  also  and 
its  vessels.  The  blood-vessels  of  the  iris 
were  slightly  enlarged,  but  not  tortuous. 
There  was  a  deep  glaucomatous  excava- 
tion of  the  nerve,  and  the  field  of  vision 
was  limited  to  the  temporal  side.  Mullen 
(Texas  Med.  Jour..  Nov..  '96). 

Primary  sarcoma  of  the  iris  may  be 
mistaken  for  gumma,  for  simple  mela- 
noma, or  for  primary  tubercle  of  the  iris. 
A  simple  melanoma  becomes  darker  and 
darker,  while  a  melanosareoma  ordinarily 
retains  its  primary  shade.    A  melanoma 


IRIS,  CILIARY  BODY,  AND  CHOROID. 


SARCOMA. 


219 


is  also  a  congenital  growth,  while  sar- 
coma is  not.  Whenever  a  gumma  of  the 
iris  appears,  there  is  a  severe  iritis, 
whereas  in  the  early  stage  of  sarcoma  of 
the  iris  there  are  no  inflammatory  symp- 
toms. In  gumma  of  the  iris  there  is  a 
specific  history,  with  other  symptoms  ref- 
erable to  syphilitic  infection.  The  color 
of  the  gumma  is  either  an  iron-red  or 
deep  yellowish  red,  while  that  of  sarcoma 
is  reddish  gray,  blackish  or  light  brown, 
or  flesh-color  (Andrews).  Gumma  is 
non-vascular  and  yellowish  white  in  color 
at  the  summit,  but  at  the  base  it  is  vas- 
cular and  has  a  yellowish-red  border 
(Fuchs).  The  administration  of  anti- 
syphilitic  remedies  for  a  short  time  in 
large  doses  will  clear  up  the  diagnosis. 

Tubercle  of  the  iris  is  of  much  more 
rapid  growth  than  sarcoma,  and  in  color 
is  of  a  light  yellowish  white,  or  light 
grayish  white,  or  light  grayish  yellow 
(Andrews).  As  a  rule,  no  vessels  are 
seen  on  its  surface,  whereas  in  sarcoma 
superficial  vascularization  can  usually  be 
detected.  The  larger  number  of  cases  of 
tubercle  have  occurred  in  subjects  under 
fifteen  years  of  age,  whereas  the  larger 
number  of  cases  of  sarcoma  have  been 
found  in  older  persons.  Tubercle  is  much 
more  irregular  in  form  than  sarcoma, 
and  the  accompanying  inflammatory 
symptoms  also  appear  earlier.  Clarence 
A.  Veasey  (Annal.  of  Ophth.,  Oct.,  '97). 

Sarcoma  of  the  ciliary  body  may  first 
manifest  itself  in  the  pupil  or  by  pushing 
forward  the  iris;  or  it  becomes  adherent 
to  the  iris  and  by  its  growth  drags  the 
iris  away  from  its  ciliary  attachment,  re- 
vealing the  tumor  beneath. 

The  fourth  reported  case  of  melanotic 
sarcoma  of  the  ciliary  body.  The  tumor 
involved  the  ciliary  body,  extending 
forward  into  the  anterior  chamber,  and 
backward  into  the  centre  of  the  vitreous, 
ir>  by  13.5  millimetres.  It  was  deep 
brown  and  light  gray  in  color,  and  di- 
vided by  strongly  pigmented  septa  into 
three  small  parts  and  one  large  portion. 
Microscopically,  it  presented  the  usual 
features  of  a  mixed-cell,  pigmented, 
choroidal  sarcoma.  Hirschberg  and  A. 
Birnbacher  (Central!),  f.  prakt.  Augenh., 
Jan.,  '95). 


Literature  of  '96-'97-'98. 

Case  of  melanosarcoma  of  the  ciliary 
body  observed  in  an  early  stage,  asso- 
ciated with  apparent  iridodialysis.  Mi- 
croscopically the  tumor  consisted  of 
round  and  spindle-shaped  unpigmented 
cells  extending  from  the  ciliary  body. 
Anteriorly  the  growth  was  preceded  by 
an  increase  in  the  pigment-cells  in  the 
ciliary  body,  the  root  of  the  iris,  and  the 
membrane  of  Descemet,  which  gave  the 
clinical  appearance  of  iridodialysis.  Pig- 
ment-cells were  also  found  between  the 
lamella  of  the  sclera,  in  the  blood-vessels, 
and  even  in  the  peribulbar  tissues,  show- 
ing an  early  metastasis.  Walter  (Archiv 
f.  Augenh.,  B.  31,  H.  11,  '96). 

Sarcoma  of  the  choroid  starts  as  a 
rounded  displacement  of  the  retina, 
which  is  not  wavy  like  an  ordinary  de- 
tachment; and  through  which  large  ves- 
sels may  be  seen. 

Case  of  melanosarcoma  of  the  choroid 
with  metastatic  deposits,  principally  in 
the  liver,  and  also  in  the  mucous  mem- 
brane of  the  bladder  and  duodenum,  the 
thyroid  gland,  the  subserous  coat  of  the 
small  intestine,  the  mediastinal,  mesen- 
teric, and  inguinal  glands,  and  the  portal 
peripancreal  glands.  Hanau  (Corres.  f. 
Schweizer  Aertze,  Apr.  1,  '91). 

Case  of  melanotic  sarcoma  of  the 
choroid  and  ciliary  body  in  a  man  62 
years  of  age.  Examination  of  the  right 
eye  showed  a  staphylomatous  condition, 
with  enlargement  of  the  blood-vessels  in 
the  lower,  outer  quadrant  of  the  globe. 
The  pupil  was  irregularly  dilated,  and 
the  iris,  which  was  bulging,  had  become 
detached  from  its  ciliary  attachment  for 
a  distance  of  four  millimetres  in  its 
lower,  outer  segment.  The  ophthal- 
moscope showed  a  dark,  nodular  mass 
occupying  a  position  corresponding  to 
the  staphyloma.  After  enucleating  the 
eye  a  piece  of  the  optic  nerve  three- 
eighths  of  an  inch  long  was  excised.  Ex- 
amination with  the  microscope  showed 
the  growth  to  be  a  melanotic  sarcoma  of 
the  spindle-celled  variety.  Seventeen 
months  later  there  was  no  manifestation 
of    a     secondary    development.  Bane 


220 


IRIS,  CILIARY  BODY,  AN 


D  CHOROID.  SARCOMA. 


(Trans.  Penna.  State  Med.  Soc.,  vol.  xx, 
'90). 

Two  cases  of  choroidal  sarcoma  in  in- 
fancy. Intra-ocular  neoplasms  occurring 
in  infancy  are  probably  sarcoma,  whether 
their  seat  of  origin  be  in  the  retina  or  in 
the  choroid.  Griffith  (Rec.  d'Ophtal., 
Sept.,  '95). 

Case  of  hereditary  sarcoma  of  the  eye- 
ball in  three  generations.  The  left  eye 
of  the  mother  and  daughter  were  affected 
with  melanotic  sarcoma,  and  it  was  stated 
that  a  sister  of  the  mother  had  died  of 
multiple  tumors,  and  had  lost  an  eye, 
and  that  the  father  and  a  twin- sister  of 
the  first  patient  had  also  lost  an  eye. 
The  nature  of  the  affection  was  unknown 
in  the  last  three  instances.  Silcock 
(Brit.  Med.  Jour.,  May  21,  '92). 

Instance  of  leucosarcoma  of'  the 
choroid  that  had  apparently  developed 
from  the  lamina  fusca.  It  was  composed 
of  two  distinct  lobes  of  unequal  size. 
Microscopically,  it  was  remarkable  on  ac- 
count of  the  huge  vascular  spaces  that 
permeated  it  in  all  directions.  Atropine, 
which  was  dropped  into  the  eye  the  bet- 
ter to  examine  that  organ,  probably  gave 
rise  to  an  increase  in  the  arterial  spaces 
of  the  tumor,  rupturing  and  precipi- 
tating an  attack  of  acute  glaucoma, 
which  had  necessitated  enucleation  of  the 
eye.  Fromaget  (Gaz.  Hebdom.  des  Sci. 
Med.  de  Bordeaux,  Aug.  20,  '93). 

Microscopical  examination  of  sarcoma 
of  the  choroid,  arising  from  injury,  made 
early  in  its  progress,  shows  that  the 
growth  is  almost  wholly  confined  to  the 
choroid.  Buller  (Trans.  Amer.  Ophthal. 
Soc,  '95). 

Choroidal  tumors  (sarcoma)  may  de- 
velop only  laterally,  and  involve  the 
whole  uveal  tract  without  projecting  into 
the  vitreous,  and  can  be  recognized  during 
life  only  very  late  in  their  course  by  the 
formation  of  episcleral  nodules.  Mit- 
valsky  (Arch,  of  Ophth.,  Oct.,  '95). 

Literature  of  JdQ-'97-'dS. 

Case  of  sarcoma  of  the  choroid  situated 
in  the  macular  region,  with  propagation 
along  the  sheath  of  the  nerve  to  the  or- 
bital tissue,  the  sclera  not  being  perfo- 
rated. The  intra-ocular  portion  of  the 
growth  was  smooth  and  flat,  and  had  not 


produced  detachment  of  the  retina,  nor 
had  it  extended  farther  into  the  globe 
after  four  years  of  observation.  Histo- 
logically, it  was  composed  of  fusiform 
cells,  relatively  poor  in  vessels,  but  con- 
taining an  abundance  of  pigment.  The 
intra-orbital  portion  was  much  larger 
and  was  lobulated  and  incapsulated. 
Histologically,  it  was  an  endothelioma 
(or  angiosarcoma),  presenting  cavities 
rilled  with  large  round  cells,  surrounded 
by  a  stroma  of  connective-tissue  bundles. 
Many  of  these  cells  had  undergone  hya- 
line degeneration  and  gave  the  chemical 
reaction  of  glycogen.  Panas  (Archives 
d'Ophtal.,  Aug.,  '90). 

From  observations  based  upon  the  mi- 
croscopical examination  of  nine  cases  of 
sarcoma  of  the  choroid  it  is  thought  that 
these  tumors  begin  in  the  vessel-walls 
and  cause  an  obstruction  to  the  venous 
circulation,  which  becomes  greater  as  the 
vertex  veins  become  involved.  As  a  re- 
sult of  the  involvement  of  the  sclera  by 
the  tumor  the  lymph-channels  also  be- 
come blocked.  In  those  cases  in  which 
there  is  greatly-increased  tension  the  ar- 
terial lumen  is  concentrically  narrowed. 
The  venous  congestion  and  increases  in 
capillary  area  produced  by  the  venous 
obstruction  cause  an  augmented  tran- 
sudation and  oedema,  especially  in  the 
ciliary  body,  and  this  is  the  cause  of  in- 
creased tension.  Schlemm's  canal  re- 
mains nearly  normal  in  all  instances,  but, 
in  cases  in  which  the  tension  remains  low, 
the  surrounding  veins  become  enlarged. 
In  cases  of  markedly-increased  tension 
the  root  of  the  iris  is  forced  against  the 
posterior  layer  of  the  cornea,  the  choroid 
pressing  against  the  sclera.  The  tension 
of  the  eyes  is  not  dependent  upon  the 
size  of  the  growth,  but  upon  its  position. 
Travis  (Ophthalmic  Record,  Apr.,  '90). 

For  many  months  or  years  uveal  sar- 
coma grows  slowly,  giving  rise  to  no  other 
symptoms;  this  is  its  first,  or  latent, 
stage.  Then  it  causes  increased  tension 
of  the  eyeball  and  inflammation;  the 
second,  or  inflammatory,  stage.  The 
third  stage  begins  when  it  perforates  the 
sclera  and  begins  to  invade  neighboring 
tissues.     It  now  grows  rapidly.  The 


IRIS,  CILIARY  BODY,  AND 


CHOROID.  TUBERCULOSIS. 


221 


fourth  stage  begins  with  the  extension 
of  the  disease  by  metastasis  to  other 
organs. 

Treatment. — The  earliest  possible  re- 
moval of  the  tumor  is  indicated.  In  a 
few  eases  of  sarcoma  of  the  iris  this  may 
be  accomplished  by  iridectomy,  removing 
the  growth  with  the  iris  from  which  it 
springs.  In  all  other  cases  the  eye  must 
be  enucleated,  and  if  perforation  of  the 
sclera  has  occurred  the  orbit  should  be 
emptied  of  its  contents. 

If  a  case  of  primary  sarcoma  in  the  iris 
be  seen  in  the  first  stage  of  the  disease, 
before  any  signs  of  surrounding  irritation 
have  appeared,  it  is  best  to  immediately 
remove  the  growth  by  an  iridectomy  so 
placed  as  to  include  the  tumor  in  the 
coloboma;  whereas,  in  those  cases  in 
which  the  second  stage  has  been  reached, 
enucleation  should  be  performed.  An- 
drews (N.  Y.  Med.  Jour.,  June  1,  '89). 

After-results  of  23  enucleations  for 
choroidal  sarcoma.  Fourteen  (over  60 
per  cent.)  were  well  at  periods  varying 
from  three  to  ten  years,  6  died  of  sarcoma 
of  the  liver,  and  the  remaining  3  died, 
but  less  certainly  from  extension  of  the 
disease.  Local  recurrence  in  the  orbit 
took  place  in  2  cases  (8  per  cent.).  Grif- 
fith (Brit.  Med.  Jour.,  Sept.  12,  '91). 

Twenty-four  cases  of  sarcoma  of  the 
uveal  tract  observed  in  the  Gottingen 
University  clinic.  In  view  of  the  pro- 
portion of  37  V2  per  cent,  of  definite 
cures  personally  witnessed,  the  prog- 
nosis does  not  seem  to  be  so  unfavorable 
as  is  generally  supposed.  It  is  recom- 
mended that  operation  should  be  done  as 
early  as  possible.  If  no  recurrence  is 
noticed  within  three  or  four  years,  the 
patient  is  tolerably  safe;  not  absolutely 
so,  however,  as  was  shown  in  1  case  in 
which  there  was  recurrence  ten  years 
after  operation.  Freudenthal  (Archiv  f. 
Ophthal.  [Grafe],  Apr.,  '91). 

Literature  of  '96-'97-'98. 

In  primary  sarcoma  of  ihe  iris,  if  the 
growth  is  sufficiently  small  and  does  not 
extend  to  the  extreme  ciliary  portion  of 
the  iris,  an  attempt  should  be  made  to 
remove  it  by  an  extremely-broad  periph- 


eral iridectomy.  If  the  growth  is  so 
large,  or  is  situated  so  near  the  ciliary 
margin  of  the  iris  that  it  is  impossible 
to  remove  all  of  it  by  an  iridectomy,  or 
if  any  other  portion  of  the  eye  has  be- 
come secondarily  involved,  immediate 
enucleation  should  be  performed.  Clar- 
ence A.  Veasey  (Annals  of  Ophth.,  Oct., 
'97). 

Tuberculosis  of  the  iris  appears  in 
isolated  gray  nodules,  usually  small  and 
scattered  throughout  the  iris,  occasion- 


Sarcoma  of  the  iris.  {Andrews.) 


ally  as  a  single  larger  growth.  In  the 
choroid  the  process  gives  rise  to  yellowish 
rounded  spots  without  pigment  change; 
and  not  attended  with  symptoms  that 
attract  attention,  being  only  discovered 
with  the  ophthalmoscope  or  post-mor- 
tem. 

Ocular  tuberculosis  is  more  frequent 
ilia n  is  generally  supposed.  Often  the 
iritis  is  assumed  to  be  rheumatic  or  luetic, 
when  careful  search  into  the  general  con- 
dition of  the  patient  and  the  family  his- 


IRON.    PREPARATIONS  AND  DOSES. 


tory  would  reveal  the  true  nature  of  the 
disorder.  The  formation  of  small  gray- 
ish-white nodules  in  the  conjunctiva, 
cornea,  or  iris  looked  upon  as  a  valuable 
diagnostic  sign.  Manz  (Munch,  med. 
Woch.,  Nov.  15,  '95). 

Three  cases  of  tuberculous  infection  of 
the  iris  found  among  40,000  eye  patients. 
The  diagnosis  is  a  difficult  one.  The  dis- 
ease may  readily  be  mistaken  for  gum- 
matous iritis  or  other  forms  of  chronic 
iritis.  It  affects  children  from  two  to 
eight  years  of  age,  is  monocular,  and  is 
almost  invariably  followed  by  fatal  tuber- 
cular meningitis.  The  disease  begins 
with  the  usual  symptoms  of  plastic  iritis. 
Later,  whitish-gray  points  are  found  on 
the  posterior  surface  of  the  cornea  and 
nodules  of  tubercle,  always  vascular,  on 
the  surface  of  the  iris.  Machek  (Wien. 
med.  Woch.,  June  16,  '94). 

Tuberculosis  of  the  iris  is  a  rare  dis- 
ease. Of  15,000  patients  personally  seen, 
only  2  had  tuberculosis  of  the  iris,  both 
dying  later  of  tubercular  meningitis. 
Three  forms  can  be  differentiated:  (1) 
tuberculous  infiltration;  (2)  dissemi- 
nated tubercles;  (3)  conglomerated 
tubercles.  Of  25  cases  recorded  in  litera- 
ture, 11  died  of  tubercular  meningitis. 
Removal  of  the  affected  part  recom- 
mended when  possible.  If  not  possible, 
then  enucleation  is  to  be  performed.  If 
other  organs  are  affected,  expectant 
treatment  alone  is  indicated.  Machek 
(Przeglad  Lekarski.  Nos.  11  and  12.  '91). 

Literature  of  '96-'97-'9$. 

Sunlight  attenuates  tuberculosis  of  the 
iris  and  makes  it  benign.  Baraquier 
(La  Sem.  Med.,  May  9,  '96). 

Tubercle  of  the  iris,  the  size  of  a  pea, 
removed.  Six  months  later  the  eye  had 
a  vision  of  one-half  of  normal.  Terson 
(La  Sem.  Med.,  May  9.  '96). 

In  tubercle  of  the  iris  partial  removal 
should  be  tried,  whenever  ii  possible. 
De  Wecker  (La  Sem.  Med..  May  9.  '96). 

Tubercle  of  the  iris  may  be  confounded 
witli  primary  sarcoma  or  witli  syphilitic 
gumma  of  the  iris.  Tubercle  i-  of  more 
rapid  growth  than  a  sarcoma,  the  color  of 
the  latter  in  the  iris  being  reddish  gray, 
blackish,  light  brown,  or  flesh-color.  It 
occurs  between  the  ago  of  twenty-four 
and  sixty,  while  tubercle  i<  usually  found 


between  the  fourth  and  twenty-first 
year.  The  color  of  gumma  is  either  an 
iron-red  or  a  deep-yellowish  red.  It  is 
always  accompanied  by  considerable  re- 
action and  generally  by  other  signs  of 
syphilitic  infection.  J.  A.  Andrews 
(Inter.  Med.  Mag.,  Aug.,  '97). 

Edward  Jackson, 

Denver. 

IRON. — Iron,  or  ferritin,  IT.  S.  P.,  as 
.\  described  by  the  pharmacopoeia,  occurs  in 
the  pure  form  of  fine,  bright,  non-elastic 
wire.    From  this  all  official  preparations 
should  be  made.    The  official  prepara- 
tions of  iron  may  be  arranged  in  four 
groups;   first,  the  bland,  or  those  de- 
void of  striking  physiological  effects, 
and  which  may  be  subdivided  into  two 
classes,  those  soluble  in  water  and  thos< 
insoluble  in  water;   second,  the  astrin- 
gent;   third,  the  compound,  in  which 
[  another  active  medicinal  agent  enters 
j  into  combination  with  the  iron;  and 
fourth,  other  official  preparations  which 
include  those  preparations  which  are  sel- 
dom used  internally  or  are  used  for  effect- 
other  than  those  properly  belonging  to 
|  iron.    A  fifth  group  may  be  added,  em- 
bracing some  of  the  non-official  prepara- 
tions of  iron  which  have  been  found  use- 
ful and  worthy  of  record.   The  iron  com- 
pounds are  also  known  as  chalybeates,  or 
j  martial  preparations.     Mineral  springs 
I  containing  iron  furnish  the  so-called 
chalybeate  waters. 

Preparations  and  Doses. 

I.  Bland  Preparations. 

(a)  Soluble  in  ^Ya^er. — Ferri  carbonas 
saccharatns,  2  to  10  grains. 

Liquor  ferri  citratis,  5  to  15  minims. 

Ferri  citras,  5  to  15  grains. 

Ferri  et  quininae  citras,  3  to  10  grains. 

Ferri  et  qnininse  citras  solnbilis,  3  to 
10  grains. 

Yinnm  ferri  amarnm.  1  to  3  drachms. 

Ferri  et  ammonii  citras,  5  to  15  grains. 

Ferri  et  strychninse  citras,  1  to  5  grains. 


IRON.    PHYSIOLOGICAL  ACTION. 


223 


Vinum  ferri  eitratis,  1  to  2  drachms. 
Ferri  et  ammonii  tartras,  10  to  30 
grains. 

Ferri  et  potassii  tartras,  10  to  30 
grains. 

Ferri  hypophosphis,  5  to  10  grains. 

Ferri  lactas,  1  to  5  grains. 

Syr.  hypophosphitnm  cum  ferro,  1/2  to 
1  1/2  drachms. 

Ferri  phosphas  solubilis,  5  to  10  grains. 

Syr.  ferri  quin.  et  strychninae  phos- 
phatum,  1/2  to  1  drachm. 

Ferri  pyrophosphas  solubilis,  2  to  5 
grains. 

(b)  Insoluble  in  Water. 

Ferrum  reductum,  1  to  5  grains. 

Pilulaa  ferri  carbonatis,  2  to  5  pills. 

Mistura  ferri  composita,  1/2  to  2 
ounces. 

Ferri  oxidum  hydratum,  1  to  4 
drachms. 

Trochesci  ferri,  1  to  6  troches. 

Emplastrnm  ferri. 

Ferri  valerianas,  1/2  to  2  grains. 

II.  ASTEINGEXT  PREPARATIONS.  

Liquor  ferri  aeetatis,  2  to  10  minims. 

Tinctura  ferri  chloridi,  5  to  20  minims. 

Liquor  f.  et  ammonii  aeetatis,  2  to  8 
drachms. 

Liquor  ferri  nitratis,  5  to  15  minims. 
Ferri  sulphas,  1  to  5  grains. 
Ferri   sulphas   exsiccatus,   1/2   to  3 
grains. 

Pilulse  aloes  et  ferri,  1  to  3  pills. 
Ferri  sulphas  granulatns,  1  to  5  grains. 
Ferri  et  ammonii  sulphas,  5  to  15 
grains. 

III.  Compound  Preparations. — 
Ferri  iodidum  saccharatum,  5  to  15 
grains. 

Pihila?  ferri  iodidi,  1  to  3  pills. 
Syrupus  ferri  iodidi.  10  to  30  minims. 

IV.  Other  Official  Preparations. 
— Ferri  ehloridum,  styptic. 

Liquor  ferri  chloridi,  styptic. 
Liquor  ferri  snbsulphatis,  styptic. 


!      Liquor  ferri  tersulphatis — pharmacy. 

Ferri  oxidum  hydratum  cum  magnesia : 
antidote  to  arsenic. 

V.  Non-official  Preparations.  — 
I  Ferratin,  8  to  30  grains. 

Ferri  arsenas,  1/16  to  1/6  grain. 

Ferri  bromidum,  5  to  20  grains. 

Syrupus  ferri  bromidi,  15  to  60  drops. 

Ferropyrin,  8  to  15  grains. 

Haunalbumin,  5  to  15  grains. 

Haemoferrum,  3  grains. 

Ilaemogallol,  2  to  8  grains. 

Haemoglobin,  75  to  150  grains. 

Haunol,  2  to  8  grains. 

Liquor  mangano-ferri  peptonatus,  2 
to  4  drachms. 

Physiological  Action. — The  experi- 
ments on  the  administration  of  inorganic 
compounds  of  iron  to  guinea-pigs  and 
other  animals,  according  to  A.  B.  Macal- 
lum,  have  resulted  in  showing  that  the 
intestinal  mucosa  absorbs  these  to  an  ex- 
tent which  varies  with  the  nature  of  the 
compound  and  with  the  quantity  of  it 
given.  When  the  dose  is  small,  absorp- 
tion occurs  only  in  that  part  of  the  in- 
testine adjacent  to  the  pylorus,  and 
measuring  only  a  few  inches  in  length; 
yet,  when  the  quantity  given  at  any  time 
is  large,  the  absorptive  area  may  embrace 
the  whole  of  the  small  intestine.  In  the 
former  case  the  result  appears  to  depend 
on  the  complete  precipitation,  as  hydrox- 
ide, of  the  iron  of  the  salt  unabsorbed, 
in  the  thoroughly-mixed  chyme,  bile,  and 
pancreatic  juice;  and,  in  the  latter  case, 
the  large  amount  of  the  iron  salt,  appar- 
ently, first  destroys  the  alkalinity  of  these 
fluids,  the  excess  of  the  salt  unaffected 
and  remaining  in  resolution  then  under- 
going absorption.  The  intestinal  epi- 
thelial cells  transfer  the  absorbed  iron  at 
once  to  the  underlying  elements  when 
the  quantity  absorbed  is  small,  but  with 
a  large  amount  absorbed  the  epithelial 
cells  are  found  to  contain  some  of  it. 


224 


IRON.    PHYSIOLOGICAL  ACTION. 


Though  some  of  the  subepithelial  leu- 
cocytes of  the  villi  appear  to  carry  part 
of  the  absorbed  iron  into  the  general 
blood-circulation,  probably  the  more  im- 
portant agent  in  the  transference  of  the 
inorganic  iron  from  the  villi  to  other 
parts  of  the  body  is  the  blood-plasma. 
Marfori's  albuminate  and  the  commercial 
"peptonate"  of  iron,  when  administered 
to  guinea-pigs,  seem  to  stimulate  the 
leucocytes  to  invade  the  epithelial  layer 
of  the  intestinal  villi.  Of  the  organic 
iron  compounds  belonging  to  the 
"chromatin"  class,  that  present  in  egg- 
yelk  (hgematogen  of  Bunge)  undergoes 
absorption  in  the  intestine  of  the  guinea- 
pig  and  of  the  Arribly stoma.  In  these, 
but  more  especially  in  the  latter,  after 
they  are  fed  with  egg-yelk  for  several 
days,  the  cytoplasm  of  the  liver-cells 
yields  marked  evidence  of  the  presence 
of  an  organic  iron  compound  belonging 
to  the  "chromatin"  class,  and  derived 
from  the  yelk  fed.  The  mode  of  absorp- 
tion of  yelk  "chromatin"  is  obscure,  but 
the  process  appears,  in  some  way,  to  be 
connected  with  the  absorption  of  the  fat 
with  which  the  iron  compound  is  closely 
associated  in  yelk. 

From  carefully-conducted  laboratory- 
experiments,  Gaule  recently  ascertained 
that  not  only  the  organic,  but  also  the 
inorganic  salts,  as  the  chloride,  are  ab- 
sorbed. The  chloride  is  absorbed,  since, 
with  the  organic  substances  in  the  stom- 
ach, it  is  changed  to  an  organic  substance. 
Absorption  takes  place  almost  exclusively 
in  the  duodenum,  although  in  the  stom- 
ach and  small  intestine  it  can  be  shown 
to  take  place.  It  may  also  take  place 
through  the  intestinal  epithelium  and 
through  the  central  vessels  of  the  cells; 
also  in  similar  manner  as  the  fats.  Two 
hours  after  the  entrance  of  the  iron  prep- 
aration into  the  intestine  there  can  al- 
ready be  shown  in  the  pulp-cells  of  the 


spleen  an  increased  deposition  of  the  so- 
called  iron-reserve.  The  progress  of  the 
iron-absorption  is  completely  normal, 
and  does  not  result  from  a  disturbance 
of  the  normal  activity. 

The  amount  of  iron  excreted  by  the 
liver,  according  to  Dastre,  is  quite  vari- 
able, but  the  mean  percentage  is  0.94  of 
the  dry  residue,  the  hepatic  iron  depend- 
ing more  on  the  blood-formation  or 
blood-destruction  in  the  liver  than  on  the 
alimentary  conditions.  A  dog  weighing 
55  pounds,  eliminates  by  the  bile,  in 
twenty-four  hours,  2  1/2  pounds  of  body- 
weight. 

Iron,  even  in  large  closes,  does  not  di- 
minish intestinal  decomposition,  and  its 
action  is  limited  to  its  combination  with 
sulphuretted  hydrogen,  which  can  then 
no  longer  exercise  any  influence  upon  the 
ferric  constituents  of  the  food.  G.  Th. 
Morner  (Wratsch,  No.  23,  "93). 

Iron  taken  by  the  mouth  is,  after  ab- 
sorption by  the  intestinal  canal,  carried 
to  the  liver.  During  its  passage  it  com- 
bines With  albumin  to  form  a  compound 
which  is  deposited  in  the  liver — perhaps 
more  than  one  compound.  In  this  organ 
it  undergoes  changes  which  fit  it  for  the 
production  of  haemoglobin.  H.  W.  F.  C. 
Woltering  (Zeits.  f.  Phys.  Chem..  '95). 

The  liver  is  especially  rich  in  iron  in 
pernicious  anaemia.  Stiihlen  (Deutsch. 
Arch.  f.  klin.  Med.,  p.  248.  'do). 

Ferric  chloride  is  transformed  in  the 
alimentary  canal  first  into  ferrous  chlo- 
ride which  combines  with  albumin  to 
form  a  soluble  product  by  which  the  iron 
is  absorbed.  Cervello  (Archivio  1 1 a  1 .  de 
Biol.,  xxv,  3). 

Microchemical  researches  on  guinea- 
pigs  and  other  animals  showing,  by  the 
ammonium-sulphide  and  bichromate-of- 
potassium  tests,  the  presence  in  the  in- 
testinal villi  and  other  tissues  of  an  in- 
creased amount  of  iron  after  ingestion 
of  salts  of  this  metal  and  organic  com- 
pounds containing  it.  Macallum  (Jour, 
of  Physiology.  '94 ) . 

It  is  very  improbable  that  iron  in  the 
form  of  inorganic  sails  introduced  into 
the  human  body  by  the  food  becomes 


IRON.    PHYSIOLOGICAL  ACTION. 


225 


converted  into  haemoglobin  by  synthesis. 
The  case  is  otherwise  with  organic  fer- 
ruginous combinations  such  as  are  pres- 
ent in  the  yelk  of  egg  in  the  form  of 
nucleoalbumins,  from  which  the  hsemat- 
ogen  originates.  Several  combinations 
of  iron  exist  in  milk  and  also  in  veg- 
etables, the  latter  containing  a  consider- 
able amount,  but  milk  only  a  small  quan- 
tity. Perhaps  the  appearance  of  chlorosis 
is  caused  by  the  fact  that  the  solid  tis- 
sues of  a  woman  abstract  iron  from  the 
blood  without  giving  anything  in  return. 
This  compensation  can  only  be  effected 
by  means  of  organic  preparations  of  iron, 
which  alone  are  absorbed. 

Ferruginous  drugs  only  act  by  sugges- 
tion,— the  iron  which  is  to  be  assimilated 
must  be  obtained  from  the  market- 
garden,  and  not  from  the  pharmacy. 
Bunge  (Lancet,  Apr.  20,  '95). 

Bunge's  hypothesis  criticised.  The 
startling  conclusion  that  the  results  of 
the  treatment  by  iron  must  be  referred 
to  the  domain  of  suggestion,  and  that  a 
diet  rich  in  iron,  particularly  meats, 
eggs,  spinach,  etc.,  should  be  substituted 
for  the  usual  method  of  administration 
refuted.  Reinert  (Wien.  med.  Blatt., 
Apr.  25,  '95). 

Death-blow  given  to  Bunge's  theory, 
that  inorganic  salts  of  iron  only  cause 
indirectly  an  accumulation  of  iron  in  the 
liver  by  uniting  with  the  H2S  in  the  ali- 
mentary canal,  and  thus  "sheltering"  the 
organic  iron  of  the  food  and  permitting 
its  absorption,  for,  when  FeS04  is  given 
to  rabbits,  iron  accumulates  in  the  liver, 
"but  not  when  salts  of  manganese,  which 
equally  unite  with  H2S,  are  substituted. 
Woltering  (Zeit.  f.  Physiol.  Chem.,  xxi, 
p.  186). 

Literature  of  '96-'97-'98. 

When  iron  in  the  form  of  carniferrin 
is  taken,  it  is  absorbed  by  the  epithelial 
cells  in  the  duodenum  alone,  because  in 
passage  of  the  intestinal  contents,  further 
on,  it  is  converted  into  an  insoluble  form 
t)y  the  SH2  and  the  products  of  decompo- 
sition. It  passes  into  the  system  in  a 
manner  which  cannot  be  clearly  ex- 
plained. In  or  after  its  passage  inward 
through  the  epithelial  cells  of  the  duo- 
denum it  becomes  more  intimately  com- 

4- 


bined  with  organic  matter,  forming  a 
compound  in  which,  as  in  haemoglobin,  it 
cannot  be  detected  by  ordinary  micro- 
chemical  methods.  It  reaches  the  system 
through  the  vena  porta.  Part  of  the  ab- 
sorbed iron  is  converted  into  haemo- 
globin; the  excess  which  is  not  required 
for  organic  vital  processes  is  stored  up, 
first  in  the  spleen  and  then  in  the  liver. 
W.  S.  Hall  (Arch.  f.  Anat.  u.  Phys.;  Phys. 
Abtheil.,  '96). 

An  iron  albuminate  passes  in  a  soluble 
condition  into  the  epithelial  cells  of  the 
duodenum,  and  is  precipitated  in  them  in 
the  form  of  granules.  It  then  passes  into 
the  central  part  of  the  villi  and  into  the 
mesenteric  glands  by  tne  aid  of  lymph- 
corpuscles.  In  part  it  seems  to  pass  in 
solution  in  the  blood-capillaries.  The  ac- 
cumulation of  iron  in  the  submucous  tis- 
sue of  the  large  intestine  is  connected 
with  its  excretion,  which  is  probably 
effected  by  the  extrusion  of  iron-laden 
leucocytes.  Hochaus  and  Quincke  (Ar- 
chiv  f.  exp.  Path.  u.  Pharm.,  pp.  159-182, 
'96). 

Experiments  made  with  newborn  dogs 
demonstrating  that  the  presence  of  iron 
salts  in  the  food  was  not  immaterial  to 
the  formation  of  haemoglobin,  that  there 
was  no  absorption  of  iron  salts,  and  that 
the  liver  seemed  to  regulate  absorption 
in  the  same  way  as  it  did  glycogenesis. 
Cloetta  (Archiv  f.  exper.  Path.  u.  Pharm., 
'97). 

The  principal  absorption  of  iron  in 
man  is  in  the  duodenum.  The  iron  is 
stored  in  the  liver  and  the  spleen,  and 
is  excreted  by  the  kidney  and  large  in- 
testine. A.  Hoffman  (Virchow's  Archiv, 
488-512,  151,  '98). 

(See  also  Anaemia  and  Anaemia,  Per- 
nicious.) 

Results  obtained  in  a  series  of  experi- 
ments performed  upon  the  lower  animals 
shows  that  iron  may  act  toxically  only 
when  it  is  injected  into  the  blood  or 
hypodermically.  The  action  is  chiefly 
manifested  by  paralysis  of  the  central 
nervous  system,  preceded  by  a  period  of 
irritation.  The  drug  produces  death  by 
asphyxia,  the  result  of  a  direct  action  on 
15 


226 


IRON.  PHYSIOLOGICAL 


ACTION.  THERAPEUTICS. 


the  respiratory  centre.  When  the  drug 
is  administered  subcutaneously  for  a 
long  time,  inflammatory  changes  are  pro- 
duced on  the  kidneys.  The  neutral  prep- 
arations of  iron  do  not  produce  symp- 
toms of  poisoning.  (Wojtaszek.) 

Iron  administered  hypodermically  re- 
mains in  the  organism  as  an  assimilable 
substance,  producing  hyperemia  in  vari- 
ous organs  and  tissues,  favoring  the  ab- 
sorption of  oedema  in  anaemic  patients, 
the  destruction  of  old  red  corpuscles,  and 
the  formation  of  new  haematins.  Rocci 
(Sixth  Italian  Congress  of  International 
Med.,  Rome;  Univ.  Med.  Jour.,  p.  366, 
'95). 

As  to  its  effects  on  metabolism,  Stock- 
man found  that  the  quantity  of  iron  in 
the  ordinary  daily  diet  of  healthy  per- 
sons with  good  appetite  averaged  from 
1/s  to  Ve  grain  a  day.  The  convales- 
cent diet  of  the  Edinburgh  Eoyal  In- 
firmary, a  sufficient  maintenance  for  per- 
sons leading  a  somewhat  inactive  life, 
contained  1/10  grain  a  day.  In  the  diet 
of  a  young  lady,  living  in  the  ordinary 
way  and  taking  an  average  amount  of 
food,  1/8  grain  was  found  in  the  daily 
diet,  while  in  that  of  two  chl orotic  girls 
who  ate  very  little  the  quantity  of  iron 
averaged  1/25  grain  a  day  (four  estima- 
tions). 

That  the  iron  metabolism  of  the  body 
must  be  small  is  evident;  the  metal  seems 
to  be  used  over  and  over  again.  The 
total  excreted  daily  by  all  channels  is 
less  than  1/10  grain  a  day. 

Less  iron  is  excreted  during  the  admin- 
istration of  iron  than  before.  This  phe- 
nomenon is  attributed  to  the  retention 
of  the  iron  by  the  tissues,  and  not  by 
the  blood.  After  intravenous  injections, 
a  considerable  amount  of  the  metal  is  ex- 
creted into  the  intestinal  tract,  and.  after 
protracted  administration  of  iron  in  this 
manner,  the  largest  amount  is  found  in 
the  liver.  Iron,  like  other  metals,  ac- 
cumulates in  the  liver.  Iron  is  poisonous 
when   injected  into  the  circulation,  and 


not  so  when  given  by  the  mouth,  because, 
in  the  first  instance,  the  metal  does  not 
all  reach  the  liver  at  once,  the  part  re- 
maining in  the  blood  acting  as  a  dele- 
terious agent;  while,  in  the  second  in- 
stance, the  iron  is  first  absorbed  by  the 
intestines,  then  taken  to  the  liver,  there 
retained,  and  from  there  enters  the  sys- 
tem gradually.  R.  Gottlieb  (Zeits.  f. 
phys.  Chemie,  B.  15,  H.  5,  '91). 

Experiments  in  regard  to  the  influence 
which  iron  exercises  over  nitrogenous 
metabolism  in  the  healthy  body  gave  the 
following  results:  1.  Iron  has  no  marked 
influence  on  nitrogenous  metamorphosis 
in  the  healthy  body.  2.  The  ingestion  of 
iron  in  daily  doses  of  0.3  to  0.5  grain 
causes  a  very  slight  decrease  in  the  as- 
similation of  the  nitrogenous  portions  of 
the  food.  3.  After  bleeding  the  assimila- 
tion of  nitrogenous  substances  increases 
a  little  whether  iron  is  used  or  not,  but 
if  iron  is  used  at  this  time  the  haemo- 
globin is  rapidly  reproduced,  and  the 
drug  would  seem  to  be  of  value  in  re- 
storing the  bodily  weight,  Skvortzoff 
(Wratsch,  No.  29,  '88). 

When  an  animal  has  been  bled,  all  the 
organs,  especially  the  liver,  are  robbed  of 
iron  to  keep  up  the  supply  of  haemoglobin 
necessary  for  life.  Kunkel  (Arch.  f.  d. 
Gesammte  Phys.,  '95). 

The  lowered  amount  of  haemoglobin 
and  the  histological  changes  of  the  blood 
depend  not  upon  the  condition  of  the 
food,  but  simply  upon  the  want  of  iron, 
since  with  this  one  cannot  only  avoid, 
but  also  improve  such  conditions.  Iron 
given  in  a  form  uncombined  with  organic 
material  is  taken  up  and  assimilated  by 
the  animal  organism.  Cappola  (Weekly 
Med.  Review.  Aug.  2.  '90). 

The  kidney  is  not  the  means  of  elimi- 
nation of  iron.  Examination  of  the  urine 
is  of  value  in  elucidating  the  question  of 
the  normal  disintegration  of  iron  in  the 
economy.  Lapicque  (Archives  do  Phys. 
Norm,  et  Path..  Xo.  2.  '9.~>i. 

Therapeutics.  —  The  chief  indication 
for  the  exhibition  of  iron  is  the  presence 
of  anaemia,  a  condition  in  which  the 
haemoglobin  of  the  blood  is  present  in  a 
less  amount  thai)  normal.  Tin1  opposite 
condition,  or  plethora,  is  a  contra-indica- 


IRON.  THERAPEUTICS. 


227 


tion.  The  haemoglobin  may  be  deficient 
in  quantity  either  from  defective  or  de- 
ficient haemogenesis  (formation  of  blood) 
or  by  reason  of  excessive  haemolysis  (de- 
struction or  breaking  up  of  the  red  blood- 
corpuscles).  The  best  results  with  iron 
are  obtained  in  cases  belonging  to  the 
former  class.  Since  anaemia  may  be  due 
to  various  causes, — an  insufficient  food- 
supply,  an  excessive  drain  or  blood-waste 
from  chronic  affections,  scrofula,  tuber- 
culosis, syphilis,  or  suppurating  abscess 
and  other  exhausting  discharges,  or  from 
repeated  haemorrhages,  or  from  the  con- 
tinued action  of  certain  poisons,  such  as 
mercury  and  lead, — it  follows  that  these 
causes  may  be  grouped  into  two  classes: 
removable  and  permanent.  In  the  for- 
mer class  we  may  expect  the  best  results 
from  ferruginous  medication. 

There  is,  notwithstanding  the  conflict- 
ing theories,  no  reasonable  doubt  that  a 
part,  at  least,  of  the  beneficial  effect  of 
iron  in  anaemia  is  due  to  its  local  action 
upon  the  digestive  organs  and  especially 
the  stomach. 

Literature  of  '96-'97-'98. 

In  cases  in  which  the  gastric  contents 
are  already  too  acid  during  digestion 
iron  accentuates  the  hyperacidity  of  the 
gastric  juice  and  aggravates  the  dyspep- 
tic symptoms  which  are  usually  present 
in  anaemia  and  chlorosis.  In  these  cases 
the  digestive  affection  must  be  set  right 
before  iron  is  administered.  In  cases, 
however,  in  which  the  secretion  of  HC1  is 
normal  or  diminished,  iron  may  often  do 
good  service  in  stimulating  the  gastric 
mucous  membrane  to  secretion.  Buz- 
dygan  (Wien.  klin.  Woch.,  No.  31,  '97). 

There  arc  two  indications  in  the  treat- 
ment of  anaemia:  to  furnish  needed  ma- 
terial to  the  blood  and  to  increase  pri- 
mary assimilation  of  food.  The  first  in- 
dication is  me1  with  small  doses  (1  or 
2  grains)  of  reduced  iron  or  of  the  car- 
bonate; as  it  has  been  estimated  that  the 


total  amount  of  iron  contained  in  the 
normal  human  blood  of  an  adult  is  only 
about  39  grains,  a  large  amount  cannot 
be  taken  up  and  assimilated  by  that  fluid. 
Clinical  experience  has  shown  that  the 
second  indication  is  best  met  by  the  ex- 
hibition of  the  astringent  preparations, 
as  the  sulphate  and  chloride,  and  of  these 
we  find  that  large  closes  act  more  cer- 
tainly and  quickly  in  many  cases  of 
anaemia,  especially  when  the  tongue  is 
broad,  flabby,  white  (from  pallor),  and 
indented  on  the  sides  by  contact  with  the 
teeth.    The  sulphate  is  one  of  the  best 
preparations  to  increase  the  appetite  and 
improve  the  digestion,  unless  the  stom- 
ach proves  intolerant.    When  feeble  di- 
gestion is  combined  with  sluggish  in- 
testinal action  the  addition  of  aloes  as 
in  the  pil.  aloe  et  ferri  is  recommended. 
Squire's  "mist,  ferri  laxans"  also  contains 
a  laxative  tending  to  antagonize  these 
untoward  conditions: — 

I>  Iron  sulphate,  2  grains. 

Magnesia  sulphate,  1  drachm. 
Dilute  sulphuric  acid,  3  minims. 
Spirit  of  chloroform,  20  minims. 
Peppermint  -  water,    to    make  1 
ounce. — M. 

Double  sulphate  of  iron  and  mag- 
nesium recommended  in  the  treatment  of 
anaemia  or  chlorosis,  in  doses  of  10  grains 
three  times  a  day.  It  has  been  used  with 
success  in  the  following  prescription:  — 

I|  Sulphate  of  iron  and  magnesium,  2 
drachms. 

Chloroform-water,  enough  to  make 
0  ounces. 

Sig. :  Half  an  ounce  three  times  a  day. 
Hugh  Woods  (Brit.  Med.  Jour.,  May  2:]. 
'01). 

Three  chlorides  elixir,  a  preparation, 
each  fluidrachm  of  which  contains  l/s 
grain  of  protochloride  of  iron,  V,_.„  grain 
of  bichloride  of  mercury,  y.JS„  of  arsenic, 
with  tincture  of  calisaya  and  aromatics, 
used  in  over  ,'300  recorded  cases  of  blood 


228 


IRON.  THERAPEUTICS. 


diseases  with  satisfactory  results.  I.  N. 
Love  (Med.  Mirror,  May,  '90). 

Syrup  of  the  chloride  of  iron,  in  its 
therapeutic  properties  and  value,  is  iden- 
tical with  the  tincture;  but  as  a  restora- 
tive agent  it  is  more  easily  assimilated, 
and  more  likely  to  be  tolerated,  by  the 
mucous  membrane  of  weak  stomachs 
than  the  old  form  of  the  chloride,  while 
it  is  less  harmful  under  prolonged  use. 
G.  W.  Weld  (Ther.  Gaz.,  '92). 

Literature  of  '96-'97-'98. 

If  the  tongue  is  heavily  coated,  the 
breath  offensive,  and  the  bowels  consti- 
pated, the  administration  of  iron  should 
be  prefaced  by  a  purge.  In  some  cases, 
however,  even  though  there  be  no  sign  of 
digestive  disorder,  the  stomach  will  not 
tolerate  any  but  the  blandest  prepara- 
tions, such  as  the  lactate  or  the  potassio- 
tartrate,  which  are  the  least  constipating 
of  the  various  preparations  of  iron. 
When  well  borne,  one  of  the  best 
preparations  of  iron  is  the  sulphate. 
It  is  generally  administered  in  pill  form, 
with  equal  parts  of  potassium  car- 
bonate. Such  a  pill  is  Blaud's.  In  an- 
aemia, dependent  upon  malarial  poison- 
ing, iron  may  be  advantageously  com- 
bined with  quinine  or  arsenic  The  ci- 
trate of  iron  and  quinine,  or  the  arsenate 
of  iron— the  latter  in  doses  of  740  grain, 
three  or  four  times  daily;  the  former  in 
doses  of  2  to  5  grains  thrice  daily — may 
be  employed.  In  the  anaemia,  which  is 
so  common  an  attendant  of  syphilis,  an 
excellent  combination  is  the  tincture  of 
the  chloride  of  iron  and  corrosive  subli- 
mate, as  in  the  following  prescription:  — 

I£  Tinct.  ferri  chloridi.  V,  ounce. 
Hydrarg.  chloridi  corros.,  1  grain. 
Glycerins?,  1/2  ounce. 
Aquae,  3  ounces. 

M.  Sig.:  One  teaspoonful  in  water, 
thrice  daily,  after  meals.  In  the  anaemia 
of  heart  disease  iron  may  be  combined 
with  digitalis.  The  two  drugs  may  be 
given  ill  pill  form,  in  which  case  the 
powdered  digitalis  should  be  employed: 
or  the  tincture  of  the  chloride  of  iron 
and  the  tincture  of  digitalis  may  be 
mingled  in  the  same  prescription.  Fred- 
erick !\  Henry  (Med.  and  Surg.  Reporter. 
Apr.  24,  '97). 


When  the  stomach  rebels  against  in- 
organic iron,  defibrinated  bnllock's  blood 
may  be  given  by  enema  or  some  of  the 
organic  preparations  may  be  adminis- 
tered internally.  In  simple  anaemia,  fer- 
ratin, in  doses  of  -i  to  8  grains,  may  be 
given  three  times  daily  in  wafers  or  pow- 
der, with  milk  or  other  liquid  food;  chil- 
dren easily  take  half  the  dose.  Haemo- 
globin, the  red  coloring  matter  of  the 
blood,  occurs  as  a  brownish-red  powder, 
which  may  be  given  in  doses  of  25  to  50 
grains,  in  wine  or  syrup,  three  times 
daily.  Haemogallol,  a  preparation  made 
from  haemoglobin,  may  be  given  in  doses 
of  4  to  8  grains,  three  times  daily,  a  half- 
hour  before  meals,  in  powder  with  sugar, 
or  in  wafers,  pills,  or  tablets.  Haemol, 
also  from  haemoglobin,  is  given  in  the 
same  manner  as  the  preceding,  in  doses 
of  4  to  8  grains.  Haemoferrum  is  an- 
other preparation  derived  from  bullock's 
blood;  it  is  given  in  doses  of  3  grains. 

Another  organic  preparation  that  lias 
found  large  use  is  liquor  mangano-ferri 
peptonatus,  or  "pepto-mangan/'  a  bland 
liquid,  usually  well  borne  by  the  stomach 
in  doses  of  1/2  to  1  tablespoonful  three 
times  daily. 


The  daily  amount  of  iron  required  is 
about  50  grains.  Iron  is  supplied  by 
vegetable  foods  of  various  kinds,  and  per- 
haps in  sufficient  quantity  for  the  needs 
of  a  healthy  person,  but  not  enough  for 
one  suffering  with  anaemia.  A  larger 
quantity  is  furnished  by  animal  food, 
particularly  milk,  eggs,  liver,  and  blood. 
The  combinations  in  the  first  three  are 
stable,  and  therefore  not  so  serviceable  as 
those  found  in  the  last.  Certain  iron- 
containing  derivatives  of  blood  may  be 
used  with  success  in  anaemia*.  Of  such, 
hamiol  and  haemogallol  are  particularly 
useful.  In  addition  there  are  certain 
artificial  products  having  definite  value, 
among  which  is  rated  ferratin.  Kobert 
(Deutsch  med.  Woch..  -Inly  12.  19.  '941. 

Ferratin  tried  in  fifteen  cases  in  which 
iron   was   indicated,  and   in   which  the 


IRON.    HYPODERMIC  USES. 


229 


stomach  was  too  irritable  to  tolerate  the 
ordinary  preparations.  There  was  no  di- 
gestive disturbance  produced  by  it;  it 
did  not  increase  the  quantity  of  haemo- 
globin more  rapidly  than  the  other  prepa- 
rations of  iron.  Max  Einhorn  (Amer. 
Therapist,  Mar.,  '95). 

Care  should  be  taken  not  to  associate 
ferratin  too  closely  with  acid  materials. 
Marfori  (Annali  di  Chim.  e  di  Farm.,  Feb. 
1,  '94). 

Clinical  investigations  with  ferratin. 
In  anaemia  following  acute  disease  the 
haemoglobin  was  quickly  increased  (over 
5  per  cent,  in  eight  days),  as  also  the 
number  of  red  cells.  In  chlorosis  the 
same  results  were  visible  even  in  a  more 
marked  degree.  The  general  condition 
was  improved  and  the  increase  in  weight 
in  most  cases  considerable.  The  good 
effects  on  the  appetite  were  obvious. 
When  compared  with  Blaud's  pills,  which 
also  give  good  results,  ferratin  was  found 
to  lead  to  a  greater  increase  in  the  haemo- 
globin. Banholzer  (Centralb.  f.  klin. 
Med.,  Jan.  27,  '94). 

Literature  of  '96-'97-'98. 

To  small  children  ferratin  is  given  in 
milk  or  other  liquid  foods,  and  it  is 
found  to  be  an  excellent  nourishment 
and  one  especially  indicated  for  such 
children  as  are  deprived  of  their  mother's 
milk  and  do  not  thrive  well  on  the  arti- 
ficial products.  G.  T.  Richardson  (N.  Y. 
Med.  Jour.,  Apr.  18,  '96). 

It  is  beneficial  to  immediately  put  a 
patient,  on  whom  an  operation  has  been 
performed,  upon  a  course  of  an  easily- 
assimilated  iron  preparation;  pepto- 
mangan  (Gude)  seems  to  be  the  best 
form  for  administration.  Von  Ramdohr 
(N.  Y.  Med.  Jour.,  June  26,  '97). 

Ferratin  tried  for  specific  blood-making 
effect  in  six  cases  confined  in  the  Cagliari 
Clinic,  and  in  five  day-patients  at  their 
dispensary.  Daily  record  kept  of  all  de- 
tails, including  blood-corpuscle  count  by 
Thoma-Zeiss  apparatus  and  haemoglobin 
estimation  by  the  chromocitometer  of 
Bizzozero.  From  this  report  are  quoted 
the  conclusions:  — 

Case  1.  December  27th,  30  per  cent, 
haemoglobin;  red  corpuscles  per  cubic 
centimetre,  3,000,000;  weight,  115  pounds. 


Ten  weeks  later,  55  per  cent,  haemo- 
globin; 4,000,000  corpuscles;  weight,  122 
pounds. 

Case  2.  December  21st,  28  per  cent, 
haemoglobin  ;  2,800,000  corpuscles  ; 
weight,  108  pounds. 

Eight  weeks  later,  55  per  cent,  haemo- 
globin; 4,000,000  corpuscles;  weight, 
127  pounds. 

Case  3.  January  27th,  60  per  cent, 
haemoglobin  ;  4,000,000  corpuscles  ; 
weight,  147  pounds. 

Three  weeks  later,  85  per  cent,  haemo- 
globin; 5,000,000  corpuscles;  weight, 
154  V2  pounds. 

Case  4.  February  18th,  20  per  cent, 
haemoglobin  ;  2,000,000  corpuscles  ; 
weight,  84  pounds. 

Nine  weeks  later,  55  per  cent,  haemo- 
globin; 4,000,000  corpuscles;  weight, 
84  V2  pounds. 

Case  5.  April  2d,  45  per  cent,  haemo- 
globin; 3,600,000  corpuscles;  weight, 
102  Y2  pounds. 

Ten  weeks  later,  65  per  cent,  haemo- 
globin; 4,000,000  corpuscles;  weight, 
116  V2  pounds.  A.  Varese  (Annali  di 
Farm,  e  Chim.,  July,  '98). 

In  chlorosis  the  use  of  iron  does  not 
yield  as  goo'd  or  as  certain  results  as  in 
anaemia;  in  fact,  some  cases  are  not  bene- 
fited at  all  by  iron  alone,  but  yield  to  a 
combination  of  iron  and  strychnine,  or 
iron  and  arsenic. 

It  has  been  found  by  clinical  experi- 
ence that  the  long-continued  use  of  iron 
may  lead  to  impairment  of  digestion, 
headache,  and  other  functional  troubles. 
It  is  well,  therefore,  to  make  occasional 
intermissions  and  to  give  a  purge  mean- 
while. It  has  also  been  found  that  good 
food,  fresh  air,  and  out-door  exercise 
favor  the  assimilation  of  iron,  although 
in  some  cases  of  profound  anaemia  abso- 
lute rest  in  bed  has  been  found  to  hasten 
recovery. 

Hypodermic  Uses. — This  mode  of  ad- 
ministration is  especially  indicated  in 
cases  of  anaemia  requiring  rapid  results 
and  when  the  remedy  is  not  well  borne 


230 


IRON.  THERAPEUTICS. 


by  the  stomach.  The  citrate  is  generally 
preferred  for  this  purpose,  the  dose  being 
one-half  that  given  by  the  month. 

Iron,  hypodermicaHy  injected,  is  effect- 
ive in  nervous  affections.  Two  prepara- 
tions recommended:  one  is  peptonized 
iron,  soluble  in  water.  A  solution  of  this 
is  made  of  the  strength  of  1  to  10.  The 
second  is  ferrum  oleatum,  diluted  in  the 
proportion  of  1  to  20  of  olive-oil.  Both 
preparations  are  employed  in  doses  of  1 
syringeful  every  second  day.  Subcutane- 
ous iron  treatment  especially  recom- 
mended in  neurasthenic  persons  and  in 
asthenic  dyspepsia  often  associated  with 
anaemia.  No  disagreeable  after-effects. 
Rosenthal  (Provincial  Med.  Jour.,  Sept., 
'91). 

After  using  subcutaneous  injections  of 
iron  in  four  cases,  experimenting  with 
both  the  citrate  and  the  ammoniocitrate, 
it  was  concluded  that  in  one  case  there 
was  more  rapid  improvement  than  is 
usually  seen  when  other  means  of  medi- 
cation are  employed.  In  two  cases,  how- 
ever, the  local  irritation  was  so  severe 
that  the  injections  had  soon  to  be 
stopped.  The  solutions  should  be  kept 
aseptic,  and  should  not  be  used  when 
more  than  eight  days  old.  H.  Rirgelen 
(Miinch.  med.  Woch.,  July  2G,  '91). 

Literature  of  '96-'97-'98. 

Iron  administered  hypodermicaHy  very 
useful  in  certain  forms  of  anaemia  when 
a  rapid  effect  is  desired,  or  when  iron  is 
not  tolerated  by  the  alimentary  canal. 
Ferrous  manganese  citrate,  made  by 
Merck,  gives  the  best  results.  The  solu- 
tions are  made  thus:  The  crystals  arc 
powdered  in  a  mortar  and  gradually  dis- 
solved in  hot  distilled  water,  1  grain  of 
the  crystals  to  5  minims  of  water.  The 
usual  dose  for  an  adult  is  15  minims, 
representing  :>  grains  of  the  compound 
salt.  The  dose  of  iron  for  hypodermic 
use  should  not.  to  begin  with,  be  more 
than  one-half  of  what  is  given  by  the 
mouth.  Da  Costa  (Ther.  Gaz.,  May  15, 
'96). 

In  the  eases  where  the  stomach  is  in- 
tolerant of  iron,  it  must  be  given  hypo- 
dermicaHy. The  citrate  of  iron  is  as 
good  as.  if  not   superior  to.  any  other 


preparation  for  the  purpose.  It  appears 
in  the  urine  half  an  hour  after  the  in- 
jection, and  is  present  for  twenty-four 
hours,  the  maximum  excretion  taking 
place  two  to  four  hours  after.  Gloevecke 
and  others  have  had  good  results  by  in- 
jecting a  10-per-eent.  solution  into  the 
buttocks  or  muscles  of  the  back,  using 
15  minims  at  a  time.  The  injection 
causes  a  sharp  pain,  which  lasts  for  some 
time,  but  that  by  using  a  larger  quantity 
(38  minims)  of  a  weaker  solution  (4  per 
cent.),  this  inconvenience  disappears  and 
there  is  only  slight  tenderness. 

A  little  over  45  grains  of  the  citrate 
when  injected  has  produced  vomiting, 
fever,  and  malaise,  lasting  several  hours. 
Great  caution  is  required  if  the  kidneys 
are  unsound,  since  even  if  they  are 
healthy  too  concentrated  injections  may 
lead,  not  only  to  the  usual  harmless  poly- 
uria, but  to  anuria  and  even  hematuria 
and  nephritis.  The  treatment  is  alto- 
gether contra-indicated  in  anaemic  pa- 
tients suffering  from  hepatic  cirrhosis, 
epistaxis,  haemorrhoids,  metrorrhagia, 
etc.,  since  it  predisposes  to  haemorrhages. 
Lepine  (Sem.  Med.,  May  20,  '97). 

Malaria.  —  The  anaemia  of  malarial 
poisoning  is  benefited  by  administration 
of  iron.  If  the  spleen  is  enlarged  and  the 
portal  circulation  engorged,  a  purge  of 
compound  jalap  powder  should  precede 
the  administration  of  the  iron,  or  po- 
dophyllin  should  be  combined  with  it. 

The  ferrocyanide  of  iron,  or  Prussian 
blue,  possesses  excellent  antiperiodic 
properties.  It  is  administered  generally 
in  5-grain  doses  every  three  hours.  The 
remedy  is  also  a  good  tonic.  Schussler 
(Chicago  Med.  Times,  Aug..  '91). 

Literature  of  '96-'d7-'d$. 

Of  five  cases  of  malarial  cachexia 
treated  with  hypodermic  injections  of 
citrate  of  iron,  four  cases  recovered  com- 
pletely. The  fifth  was  greatly  improved. 
Xaame  (Rev.  de  Med.  de  Paris,  Mar.  lit. 
'97). 

Pseudoleukemia.  —  In  leucocythaB- 
mia  iron  is  of  little  service,  but  in 
psendolencocythannia    (Hodgkin's  di>- 


IRON.  THERAPEUTICS. 


231 


ease,  or  splenic  cachexia)  it  is  highly 
useful . 

Literature  of  '96-'97-'98. 

In  series  of  cases  of  leukaemia  and  per- 
nicious anaemia  was  1  case  in  which  the 
patient  improved  markedly  under  the 
use  of  arsenic  and  iron  sulphate,  the 
red  corpuscles  increasing  from  886,000  to 
4,360,000  during  one  period  of  the  treat- 
ment, H.  A.  Hare  (Med.  News,  Mar.  27, 
'97). 

Venereal  Disorders. — In  the  anae- 
mia of  syphilis  the  use  of  the  iodide  of 
iron  is  indicated. 

In  sloughing  phagedena  or  chancroid, 
the  anaemia  incident  to  those  affections 
is  best  treated  by  the  iodide  of  iron,  al- 
though many  prefer  the  tartrate  of  iron 
and  potash. 

Twenty-five  cases  of  spermatorrhoea 
treated  with  ferric  bromide.  Of  this 
number  19  were  completely  cured,  2  only 
being  unrelieved.  The  dose  is  3  to  5 
grains  given  either  in  solution  or  in  the 
form  of  a  lozenge.  The  ferric  bromide  is 
to  be  preferred  to  the  corresponding  fer- 
rous compound.  Hecquet  (Ther.  Gaz., 
Feb.,  '91). 

Rheumatism. — Though  not  very  often 
used,  in  acute  rheumatism  the  tincture  of 
the  chloride  in  doses  of  20  to  30  minims, 
well  diluted,  every  four  hours,  will  di- 
minish the  pain,  fever,  and  sweating  and 
lessen  the  danger  of  cardiac  mischief.  It 
will  hasten  convalescence  and  may,  more- 
over, be  used  as  a  prophylactic  against 
acute  rheumatism  in  weak  and  cachectic 
subjects  (Anstie),  but  not  in  the  robust 
or  full-blooded  (Bartholow). 

The  succinate  (hydrated)  of  iron  is  the 
most  palatable  preparation  of  iron.  The 
tasteless  succinate,  in  combination  with 
an  elixir,  is  permanent  under  all  circum- 
stances. Combined  with  syrup  trifolium 
compound,  the  succinate  of  iron  will  be 
found  without  a  rival  in  the  treatment 
of  rheumatism  and  the  various  forms  of 
syphilis.  It  is  similarly  useful  for  the 
amentia   of  chronic   malarial  poisoning, 


and  is  indicated  in  the  treatment  of  ery- 
sipelas, pulmonary  haemorrhage,  haemor- 
rhage of  the  bowels,  and  other  intestinal 
disorders.  It  should  be  given  in  small 
quantities  at  the  beginning,  gradually 
increasing  the  dose.  William  Thornton 
Parker  (Med.  Age,  Dec.  26,  '91). 

Erysipelas. — The  treatment  by  iron 
is  not  new,  but  it  is  for  that  reason  none 
the  less  satisfactory.  Large  doses — 10  to 
60  minims — of  the  tincture  of  the  chlo- 
ride, well  diluted,  may  be  given  every 
four  hours  with  advantage. 

Bromide  of  iron  believed  to  be  one  of 
the  best  preparations  for  internal  admin- 
istration, as  it  is  easily  and  quickly  as- 
similated. It  is  especially  valuable  as 
a  topical  application,  in  foetid  discharges 
and  gangrenous  ulcers.  In  erysipelas  it 
acts  as  a  specific.  In  such  cases  it  must 
be  freely  used,  painted  over  and  beyond 
the  infected  integument.  Gillespie  (Pa- 
cific Record  of  Med.  and  Surg.,  July  15, 
'90). 

Iron  takes  into  the  blood  the  oxygen 
required,  which,  coming  in  direct  contact 
with  the  streptococci  of  erysipelas,  causes 
their  .  destruction.  If  iron  be  given  all 
the  time  in  this  disease,  and  the  patient 
placed  in  an  aerated  chamber  where  oxy- 
gen may  be  generated,  the  records  would 
show  a  considerable  decrease  in  mortality 
from  erysipelas  and  kindred  affections. 
J.  A.  Crisler  (Memphis  Med.  Monthly, 
Apr.,  '90). 

Diphtheria.  —  The  tincture  of  the 
chloride  is  given  internally  to  support  the 
organism,  either  alone  or  combined  with 
chlorate  of  potash,  quinine,  or  strych- 
nine. The  use  of  the  chlorate  of  potash 
in  this  disease  is,  however,  objected  to  on 
the  ground  that  it  induces  destructive 
changes  in  the  renal  tissue.  MonseFs 
solution  (liq.  ferri  subsulphatis)  may  be 
used  locally  upon  the  tonsils  and  phar- 
ynx, either  pure  or  diluted  with  two  or 
three  parts  of  glycerin.  It  constringes 
the  tissues  and  appears  to  limit  the 
extension  of  the  exudate.  This  latter 
application  may  be  used  in  the  same 


232 


IRON.  THERAPEUTICS. 


manner  in  follicular  tonsillitis  with  ad- 
vantage. 

Value  of  perchloride  of  iron  in  prevent- 
ing the  spread  of  diphtheria  from  the 
pharynx  to  the  larynx.  The  2-per-cent. 
perchloride  in  glycerin  is  given  hourly, 
night  and  day,  in  teaspoonful  or  dessert- 
spoonful doses.  N.  Rosenthal  (Ther. 
Monats.,  Dec,  '92). 

Application  of  perchloride  of  iron  in 
diphtheria  made  twice  daily  if  the  cases 
be  light,  and  three  times  daily  if  they  be 
serious.  The  drug  is  used  either  in  a 
pure  state  or  in  one-half  or  one-fifth  solu- 
tion. The  healthy  adjoining  tissue  is  not 
injured  by  the  treatment.  T.  Huebner 
(Ther.  Monats.,  Dec,  '92). 

Applications  of  pure  perchloride  of  iron 
recommended  in  pharyngeal  diphtheria. 
The  suffering  which  the  applications 
cause  is  most  intense,  but  three  or  four 
are  sufficient  to  vanquish  the  disease.  Of 
thirty-six  cases  personally  treated  there 
was  but  one  death:  from  enormous 
ganglionic  tumefaction.  Feige  (Ther. 
Monats.,  July,  '94). 

Scrofulosis. — In  scrofulous  adenitis 
and  rachitis  the  syrup  of  the  iodide  is 
beneficial.  It  is  best  to  begin  with  small 
doses,  gradually  increasing  the  same  as 
tolerance  is  established.  The  combina- 
tion of  the  phosphates  of  iron  and  lime 
are  preferred  by  some  in  rachitis.  Cod- 
liver-oil  given  with  iron  increases  the 
efficiency  of  the  former  in  these  cases. 

Neuroses. — Neuralgia  due  to  anaemia 
is  greatly  benefited  by  large  doses  (30  to 
40  minims)  of  the  tincture  of  the  chlo- 
ride or  by  20  grains  of  the  saccharated 
carbonate,  given  three  times  daily.  Fer- 
ropyrin,  one  of  the  newer  preparations, 
may  be  given  in  doses  of  4  to  8  grains  in 
these  cases. 

In  the  anaemic  forms  of  mental  dis- 
eases Bucknill  and  Tuke  advised  the  ad- 
ministration of  the  tincture  of  the  chlo- 
ride of  iron. 

In  hysteria  associated  with  anaemia 
the  valerianate  of  iron  may  be  given  in 
pill  in  doses  of  1  to  5  grains,  three  times 


daily.  Amenorrhcea  and  other  derange- 
ments of  the  menstrual  function  depend- 
ent upon  anaemia  are  benefited  by  the 
citrate  of  iron  alone  or  combined  with 
strychnine. 

Literature  of  '96-'97-'98. 

A  great  many  cases  of  dysmenorrhoea 
occur  in  anaemic  young  women,  and  full 
doses  of  iron  will  cure  the  anaemia  and 
with  it  the  dysmenorrhea.  I.  Parsons 
(Brit.  Med.  Jour.,  Oct.  24,  '96). 

In  epilepsy  and  chorea  in  weak  and 
anaemic  pupils  the  use  of  the  bromide  of 
iron  is  recommended  by  Da  Costa,  the 
bromide  in  doses  of  5  to  20  grains  or, 
preferably,  the  syrup  of  the  bromide  in 
doses  of  1/2  to  1  teaspoonful. 

Pulmonary  Disorders. — When  there 
is  anaemia  the  bland  preparation  seems 
to  agree  best.  Iron  is,  however,  contra- 
indicated  when  pulmonary  haemorrhage 
exists  or  threatens  and  in  all  acute  pul- 
monary affections. 

Hectic  fever  is  controlled  by  a  com- 
bination of  digitalis  and  iron:  5  drops  of 
the  tincture  of  digitalis  may  be  given 
with  10  drops  of  the  tincture  of  the  chlo- 
ride of  iron,  three  or  four  times  daily. 

Cardiac  Diseases.  —  In  the  various 
cardiac  affections  the  administration  of 
iron  is  generally  beneficial.  In  fatty  de- 
generation of  the  heart  iron  does  good 
by  improving  the  nutrition  of  the  organ. 
The  palpitation,  murmur,  and  precordial 
distress  of  anaemia  and  chlorosis  are  re- 
lieved by  iron.  When  the  cavities,  espe- 
cially on  the  right  side,  are  dilated,  and 
cough,  dyspnoea,  and  dropsy  are  present, 
iron  often  affords  greater  relief  than 
cardiac  sedatives  and  diuretics  (Bar- 
tholow).  In  these  cases  and  in  mitral 
regurgitation,  as  the  distress  is  increased 
by  the  thinness  of  the  blood,  Bartholow 
advises  the  following  pill,  three  times 
daily:  Reduced  iron,  quinine  sulphate, 
and  powdered  digitalis  (English),  of  each, 


IRON.  THERAPEUTICS. 


233 


1  grain;  powdered  squill,  1/2  grain.  In 
valvular  lesions  iron  may  be  used  if 
anaemia  be  present.  Plethora  interdicts 
its  use. 

Eenal  Diseases.  —  In  this  class  of 
affections  iron  should  be  given  with 
prudence,  especially  in  chronic  nephritis. 

In  chronic  albuminuria  the  tincture  of 
the  chloride  improves  the  digestion  and 
counteracts  the  anaemia.  Many  prefer 
Basham's  mixture  (liquor  ferri  et  am- 
monii  acetatis),  2  to  4  drachms  three  or 
four  times  daily,  on  account  of  its  di- 
uretic action. 

Literature  of  '96-'97-'98. 

There  is  a  good  deal  of  mischief  done 
by  iron  in  Bright's  disease.  Basham's 
mixture  in  Bright's  disease  was  never 
suggested  for  any  directly  curative  pur- 
pose, but  simply  as  a  remedy  for  the 
anaemia  which  is  so  conspicuous  a  symp- 
tom in  many  cases,  and  for  this  purpose 
it  still  is  and  always  will  be  useful.  But 
not  every  case  of  Bright's  disease  is 
-  anaemic,  and  as  iron  has  no  specific  cura- 
tive effect  it  is  clearly  not  indicated  in 
non-anaemic  cases.  Nay,  more,  it  is  often 
harmful.  It  may  be  laid  down  as  a  rule 
to  which  there  is  almost  no  exception 
that  iron  is  not  indicated  and  should 
not  be  prescribed  in  cases  of  acute 
Bright'  disease.  On  the  other  hand,  after 
the  acute  symptoms  have  passed  away 
and  convalescence  sets  in,  iron  is  often 
very  useful. 

A  second  class  of  cases  in  which  iron 
is  contra-indicated  is  chronic  interstitial 
nephritis,  in  which  it  is  more  promptly 
and  dangerously  harmful  than  in  any 
other  form  known  of  Bright's  disease. 

The  form  of  Bright's  disease  in  which 
iron  is  best  borne  is  chronic  parenchy- 
matous nephritis.  And  as  this  is  apt  to 
be  associated  with  more  or  less  anaemia, 
it  becomes  a  most  valuable  remedy  in 
overcoming  this  symptom.  Even  here 
the  doses  given  are  usually  needlessly 
large.  The  author's  practice  is  to  deter- 
mine the  proper  dose  by  an  examination 
of  the  stools,  and,  if  these  are  decidedly 
blackened,  too  much  is  being  given.  On 
the  other  hand,  a  slight  coloration  may 


be  permitted.  Basham's  mixture  is  no 
more  diuretic  than  the  bulk  of  water 
which  constitutes  its  menstruum.  James 
Tyson  (Jour.  Amer.  Med.  Assoc.,  July 
23,  '98). 

Haemorrhage. — The  astringent  prep- 
arations of  iron  are  useful  in  haemor- 
rhage.  In  the  passive  haemorrhages  (pur- 
pura; hemorrhagic  diathesis;  gastric,  in- 
testinal and  renal  haemorrhage  when  due 
to  anaemia)  the  tincture  of  the  chloride, 
taken  internally,  improves  the  tone  of 
the  vessels  and  the  quality  of  the  blood. 
Iron-quinine    chloride    is  exceedingly 
useful  in  cases  of  post-abortum  haemor- 
rhages, in  doses  of  10  drops,  every  one  or 
two  hours,  of  a  10-per-cent.  solution.  It 
is  likewise  of  value  in  cases  of  pulmonary 
haemorrhage,  and  in  profuse  menstrua- 
tion, in  doses  of  10  drops  five  or  six  times 
a  day.    J.  Kersch  (Pharm.  Post,  Mar.  1, 
'91). 

Case  of  a  woman,  37  years  of  age,  suf- 
fering from  aneurismal  dilatation  of  the 
right  carotid,  who  after  an  abortion  and 
a  tedious  convalescence  again  became 
pregnant  and  went  to  full  term  without 
any  specially  untoward  symptom.  In  the 
second  week  after  delivery  she  began  to 
show  decided  signs  of  anaemia.  She  was 
given  tr.  chloride  of  iron  for  weeks,  but 
gained  very  little  and  the  breast-milk 
lessened  very  much.  After  the  use  of 
ferratin,  15  grains  daily,  the  improve- 
ment was  decided  in  five  days,  anaemia 
disappearing  and  the  supply  of  milk  re- 
turning. S.  Wolfe  (N.  Y.  Med.  Jour., 
Dec.  7,  '95). 

Literature  of  '96-'97-'98. 

Persulphate  of  iron,  combined  with  in- 
halations of  oxygen  and  careful  hygienic 
regulations,  most  useful  in  treatment  of 
haemoglobinuria.  Baccelli  (Gaz.  degli 
Osped.  e  delle  Clin.,  Feb.  15,  '97). 

Ferratin  has  had  a  limited,  but  suc- 
cessful, trial  in  the  New  Haven  Hospital. 
It  has  been  used  in  secondary  anaemias 
due  to  haemorrhage  following  childbirth, 
etc.  In  primary  anaemia  it  has  been  used 
very  little.  The  results  have  usually 
been  prompt  and  satisfactory.  Hospital 
and  Clinic  Notes  (Yale  Med.  Jour.,  June, 
'98). 


234  IRON. 

Li  epistaxis  and  chronic  coryza  a  weak 
dilution  of  the  liquor  ferri  subsulphate 
(1  drachm  to  8  ounces  of  water)  has  been 
advised,  to  he  used  in  spray.  The  same 
application  has  been  used  in  pulmonary 
haemorrhage.  As  it  stains  the  teeth,  its 
use  is  objectionable. 

Ferripyrin  is  a  valuable  styptic  and 
astringent,  having  the  advantage  over 
perehloride  of  iron  in  not  acting  as  a 
caustic.  When  applied  to  the  mucous 
membrane  of  the  nose  it  acts  as  a  power- 
ful astringent  and  produces  a  slight  an- 
aesthetic effect.  It  is  used  in  the  form  of 
an  18-  to  20-per-cent.  solution,  pledgets 
of  cotton-wool  soaked  in  this  being  ap- 
plied to  the  bleeding-parts.  For  gonor- 
rhoea injections  of  1 1/2-per-cent.  solution 
may  be  used.  In  haematemesis  doses  of 
7  to  8  grains  should  be  given.  Jurasz 
(Ther.  Monats.,  Feb.,  '95). 

Ferripyrin  has  the  same  indications  as 
perehloride  of  iron,  with  fewer  objections. 
It  appears  preferable  as  an  haemostatic. 
C.  Calderone  (Archivio  de  Pharm.  e  Tera., 
Feb.,  '95). 

Ferripyrin,  a  new  haemostatic,  is  a  com- 
bination of  perehloride  of  iron  and  anti- 
pyrine.  It  is  a  very  fine  orange-colored 
powder,  soluble  in  water,  the  solution 
being  deep  red  in  color.  It  is  intended  as 
a  substitute  for  perehloride  of  iron,  and 
the  indications  for  its  use  are  the  same. 
The  dose  for  an  adult  is  7  3/4  grains  in- 
ternally, mixed  with  an  oily,  sweet  prep- 
aration of  menthol.  It  is  of  value  in 
gastrorrhagias.  For  external  use  and  as 
an  haemostatic,  either  the  powder  or  an 
18-  to  20-per-cent.  solution  may  be  em- 
ployed, cotton  tampons  being  saturated 
in  the  solution  and  applied  to  the  bleed- 
ing surface.  In  1-  and  1  l/2-per-cent.  solu- 
tions it  is  recommended  as  an  astringent 
in  urethral  blennorrhagia.    Epistaxis  in 


JABORANDI. 

a  case  of  nasal  myoma  was  arrested  in  a 
very  short  time  by  the  introduction  of 
two  small  tampons  soaked  in  ferripyrin. 
The  drug  is  free  from  the  caustic  effects 
produced  by  perehloride  of  iron.  L.  Hed- 
derich  (Munch,  med.  Woch.,  Xo.  1,  '95). 

In  haematemesis,  1  or  10  drops  of  the 
solution  of  the  subsnlphate,  or  pernitrate, 
well  diluted  in  ice-water,  will  generally 
be  followed  by  relief.  The  tincture  of 
the  chloride  may  be  similarly  used. 

In  intestinal  haemorrhage  iron  is  less 
beneficial,  as  it  becomes  converted  into 
the  inert  sulphide  as  it  descends  the  ali- 
mentary canal. 

Local  Uses. — The  bleedings  from 
haemorrhoids  may  be  diminished,  or  even 
arrested,  by  bathing  the  protruding 
tumors  with  Monsel's  solution.  The 
tumors  should  be  well  oiled  before  re- 
turning them.  The  haemorrhage  from 
leech-bites  and  after  the  extraction  of 
teeth,  and  the  oozing  from  surface  in 
minor  surgical  operations  may  lie  ar- 
rested by  the  application  of  Monsel's  salt 
or  solution  combined  with  pressure,  when 
possible.  Fissured  nipples  may  be  healed 
by  brushing  the  fissures  with  Monsehs 
solution  diluted  with  three  parts  of  glyc- 
erin. Syphilitic  vegetations  of  the  glans 
and  prepuce  will  disappear  under  appli- 
cations of  pure  Monsel  solution:  Asear- 
ides  vermiculares  may  be  removed  by  in- 
jections of  weak  dilutions  of  t  he  tincture, 
and,  as  anaemia  is  usually  present  in  these 
cases,  the  internal  use  of  iron  is  advised. 

0.  SlJMNEB  WlTHERSTINE, 

Philadelphia. 

ITCH.    See  Scabies. 


J 

JABORANDI. — Jaborandi  (Pilocarpus,  ing  to  the  family  Rutacece.  The  leaflets 
U.  S.  P.)  is  the  dried  leaflets  of  the  South  have  an  aromatic  odor,  and  an  aromatic, 
America  trees  Pilocarpus  sellvanus  (Rio  bitter,  and  pungent  taste.  When  chewed 
Janeiro  jaborandi)  and  Pilocarpus  jabo-  they  produce  an  increased  How  of  saliva. 
randi  (Pernambuco  jaborandi),  belong-     Jaborandi  contains  two  alkaloids  (pilo- 


JABORANDI.    PHYSIOLOGICAL  ACTION.    POISOXIXG  BY  PILOCARPIXE.  235 


carpine  and  jaborine),  a  volatile  oil, 
jaboric  acid,  and  tannin.  Chemically  the 
two  alkaloids  are  similar.  The  physio- 
logical actions  of  the  two  alkaloids  are 
widely  different.  The  alkaloid  pilocar- 
pine is  non-crystallizable,  and  occurs  as 
a  colorless  or  yellow  syrupy  liquid,  which 
is  soluble  in  water,  alcohol,  ether,  and 
chloroform.  The  salts  of  pilocarpine  are 
crystallizable.  The  hydrochlorate  is  offi- 
cial and  occurs  in  white,  hygroscopic 
crystals,  of  a  slightly-bitter  taste  and  of 
an  acid  reaction;  it  is  soluble  in  water 
and  alcohol,  and  does  not  keep  well. 

A  preparation  of  pilocarpine  previously 
active  may  suddenly  lose  all  its  power. 
H.  Magnus  (Ther.  Monats.,  Feb.,  '88). 

Jaborine  is  never  used  in  medicine, 
and  has  an  effect  antagonistic  to  pilo- 
carpine, or  like  atropine. 

Preparations  and  Doses. — Pilocarpus, 
5  to  50  grains. 

Extract  or  extractum  pilocarpi  flui- 
dum,  10  to  60  minims. 

The  hydrochlorate  of  pilocarpine  (pilo- 
carpine hydrochloras),  1/8  to  1/2  grain. 

Physiological  Action.  —  A  medicinal 
dose  of  jaborandi  causes  flushing  of  the 
face  and  neck,  followed  by  profuse  sweat- 
ing of  the  entire  surface,  marked  saliva- 
tion, and  occasionally  nausea.  In  some 
subjects,  and  particularly  in  children, 
even  large  doses  produce  no  effect. 

Toxic  doses  cause  depression  of  the 
nerve-centres,  but  normal  doses  seem  to 
slightly,  if  at  all,  influence  the  nervous 
system.  The  pulse  of  animals  is  slowed 
by  jaborandi;  but  this  does  not  seem  to 
be  the  case  in  man,  in  which,  on  the  con- 
trary, the  pulsations  are  increased  in 
number.  The  temperature  is  markedly 
lowered  after  a  rise  of  short  duration. 

Pilocarpine,  according  to  Reiehert, 
first  increases  and  then  decreases  bodily 
temperature.  Heat-production  and  heat- 
dissipation  are  first  increased  and  then 


diminished.  The  alterations  in  tempera- 
ture are  dependent  essentially  upon  the 
actions  on  heat-production,  but  may  be 
affected  «by  sweating,  and,  after  very 
large  doses,  by  alterations  in  heat-dissipa- 
tion. The  primary  increase  of  tempera- 
ture is  due  at  first  to  an  increase  of  heat- 
production,  but  after  very  large  doses 
this  increase  may  be  exaggerated  and 
continued  by  a  diminution  of  heat-dis- 
sipation which  is  greater  than  the  depres- 
sion of  heat-production.  The  actions  on 
the  process  of  heat-production  are  so 
much  more  potent  in  their  effects  on 
temperature  than  those  on  the  sweat- 
glands  that  it  is  doubtful  if  the  latter 
ever  play  an  important  part  in  the  tem- 
perature-alterations. Bodily  tempera- 
ture may  be  increased  during  the  stage 
of  diminished  heat-production,  owing  to 
the  great  depression  of  heat-dissipation. 
The  amount  of  increase  and  decrease  of 
temperature  and  the  duration  of  each 
of  these  periods  are  essentially  in  direct 
relation  to  the  dose. 

Horbaczewski  found  that  pilocarpine 
caused  an  increase  in  the  number  of  leu- 
cocytes in  the  blood  and  a  correlative  in- 
crease in  the  quantity  of  uric  acid.  The 
excretion  of  urea  is  markedly  increased. 

The  influence  of  jaborandi  upon  the 
renal  system  differs  with  the  dose  admin- 
istered. Lare  doses,  by  diminishing  the 
body-liquids  through  the  profuse  sweat- 
ing induced,  decrease  the  quantity  of 
urine;  small  doses  increase  the  flow. 

As  to  the  direct  cause  of  the  sweating, 
it  is  thought  to  depend  upon  stimulation 
of  nerve-ends  of  the  sweat-glands  and 
upon  paralysis  of  the  vasomotor  nerves, 
as  would  naturally  be  inferred. 

Poisoning  by  Jaborandi  or  Pilocar- 
pine.— Serious  and  even  fatal  results 
have  followed  the  injection  of  medicinal 
doses  of  pilocarpine;  x/3  grain  of  pilo- 
carpine has  caused  profuse  diaphoresis, 


236 


JABORANDI.  THERAPEUTICS. 


salivation,  lacrymation,  a  discharge  from 
the  nose,  sickness  of  the  stomach,  diffi- 
culty in  breathing,  and  a  sense  of  car- 
diac oppression.  Bemy  mentions  a  case 
in  which  the  remedy  induced  a  series  of 
epileptic  attacks.  In  another  case  the 
patient  suddenly  expired  directly  after 
an  injection  had  been  made.  The  use  of 
lethal  doses  is  usually  followed  by  copi- 
ous sweating,  dizziness,  salivation  and 
swelling  of  the  salivary  glands  and  ton- 
sils, lacrymation,  discharge  from  the 
nose,  hiccough  and  strangling,  vomiting, 
diarrhoea,  a  tearing  pain  in  the  eyeballs, 
myopia,  dimness  of  vision,  strongly-con- 
tracted pupils,  dyspnoea,  and  more  or  less 
cardiac  oppression,  and  sometimes  bloody 
leucorrhoea  is  seen.  These  effects  and 
the  report  of  occasional  cases  of  accident 
following  the  administrations  of  medic- 
inal doses  should  teach  caution  in  the  use 
of  the  remedy. 

Caution  advised  in  the  use  of  what 
may  prove  a  dangerous  drug,  as  fatal  or 
alarming  symptoms  may  be  produced  by 
pilocarpine.  Lanphear  (Kansas  City 
Med.  Index,  Nov.,  '88). 

Treatment  of  Poisoning  by  Jaborandi. 
— The  untoward  symptoms  of  poisoning 
by  jaborandi  indicate  the  use  of  active 
external  and  internal  stimulation.  If 
taken  by  the  mouth,  use  emetics  or  a 
stomach-siphon  to  wash  out  any  portion 
of  the  drug  that  may  be  present  in  the 
stomach.  Atropine  or  any  preparation 
of  belladonna  may  be  used  as  a  physio- 
logical antidote.  Ammonia  and  brandy 
should  be  given  freely.  The  vomiting 
may  be  controlled  by  morphine. 

Therapeutics.  —  The  therapeutics  of 
jaborandi  accord  strictly  with  its  physio- 
logical action,  for  it  is  mainly  employed 
for  its  property  of  producing  sweating. 
As  it  is  the  most  powerful  remedy  we 
possess  for  this  purpose,  it  should  be  used 
with  great  caution,  as  it  is  much  more 
depressing  than  the  use  of  the  hot-air 


bath,  water  packs,  etc.;  it  should  not  be 
used  in  cases  of  asthenia  or  adynamia, 
or  in  pronounced  embarrassment  from 
organic  diseases,  pulmonary  congestion 
or  oedema,  threatening  or  existing,  or  in 
irritation  or  inflammation  of  the  ali- 
mentary canal. 

Uremia  and  Nephritis.  —  Pilocar- 
pine is  generally  to  be  preferred  to  jabo- 
randi, as  it  is  less  likely  to  produce 
nausea  and  vomiting. 

Jaborandi  and  its  alkaloid,  pilocarpine, 
are  agents  that  are  extremely  useful  in 
ura?mia,  fever,  desquamation,  or  chronic 
parenchymatous  nephritis,  since  they 
markedly  increase  the  elimination  of 
urea  by  the  skin;  lower  the  blood-press- 
ure, and  diminish  the  inflammatory  con- 
dition. In  acute  scarlatinal  nephritis 
pilocarpine  is  of  the  greatest  service,  in- 
creasing the  urinary  secretion  and  de- 
creasing the  albumin  and  the  blood. 
Shoemaker  suggests  the  following  for- 
mula : — 

I^  Extract  of  jaborandi,   1/2  fluid- 
ounce. 

Solution  of  potassium  citrate,  2 

fluidounces. 
Syrup  of  orange,  1 1/2  fluidounces. 
Mix  and  give  a  teaspoonful  or  two 
every  three  or  four  hours. 

Cardiac  depression  may  be  avoided  by 
the  exhibition  of  strychnine  and  alcohol. 
In  the  uraemia  of  pregnancy  and  puer- 
peral eclampsia  the  hypodermic  injection 
of  pilocarpine  may  be  of  marked  benefit, 
but  in  some  cases  it  does  more  harm  than 
good  by  its  depressing  influence.  In  the 
nephritis  of  middle  and  advanced  life, 
many  authorities  consider  that  pilocar- 
pine is  contra-indicated.  As  a  renal 
stimulant  pilocarpine  may  be  given  in 
doses  of  1/80  to  V20  grain,  either  by  hyp- 
odermic injection  or  by  the  month. 

An  alarming  case  of  uremic  convul- 
sions relieved  repeatedly  by  the  hypo- 


JABORANDI.  THERAPEUTICS. 


237 


dermic  use  of  pilocarpine  until  complete 
recovery  ensued.  W.  J.  F.  Churcnouse 
(Brit.  Med.  Jour.,  Jan.  26,  '88). 

Pilocarpine  tried  in  a  number  of  cases 
of  ursemic  poinsoning,  but  all  of  them 
died.  Van  Eman  (Kansas  City  Med. 
Index,  Nov.,  '88). 

Pilocarpine  in  Bright's  disease  will 
nearly  always  diminish  dropsy  suffi- 
ciently to  protect  more  or  less  against 
the  danger  of  suffocative  attacks,  even 
when  hot-air  baths  and  other  diapho- 
retics prove  useless.  D.  Benezur  and  S. 
Csatary  (Brit.  Med.  Jour.,  Feb.  25,  '88). 

Case  of  Bright's  disease  in  which  hypo- 
dermic injections  of  V4  grain  of  pilocar- 
pine greatly  reduced  the  cedema  and 
dropsy.  J.  G.  Marshall  (.Lancet,  Jan.  12, 
'89). 

Pilocarpine  exercises  a  decided  diuretic 
action,  under  normal  circumstances;  its 
power  is  easily  masked,  by  the  marked 
increase  which  it  produces  in  other  se- 
cretions. Pilocarpine  causes  a  diminution 
in  the  volume  of  the  kidney  and  an  in- 
crease of  the  arterial  pressure,  these 
effects  being  due  to  a  direct,  stimulating 
action  upon  the  coats  of  the  blood-vessels. 
Sabbatani  (Jour,  de  Med.,  de  Chir.,  et  de 
Pharm.,  May  6,  '93). 

Pilocarpine  is  of  great  service  as  a 
sialagogue,  in  doses  of  Vo  to  1/3  grain  by 
subcutaneous  injection.  Marked  benefit 
observed  from  its  use  in  cases  of  uraemia, 
beginning  meningitis,  chronic  meningitis ; 
in  affections  of  the  naso-pharynx  and 
larynx,  especially  in  cedema  of  the  glot- 
tis; in  scarlatinal  nephritis,  and  in  the 
initial  stages  of  peripheral  and  spinal 
affections.  It  is  sometimes  desirable  to 
associate  it  with  iodide  of  potassium  and 
red  iodide  of  mercury.  Hartcop  (Cen- 
tralb.  f.  klin.  Med.,  No.  41,  '94). 

Passive  Effusions. — Pilocarpine  has 
been  used  in  dropsy,  ascites,  and  hydro- 
thorax.  In  dropsy  of  renal  origin  it  is  a 
valuable  agent,  but  when  due  to  cardiac 
trouble  it  is  too  depressing.  In  hydro- 
thorax  it  is  of  considerable  value,  but 
thoracentesis  is,  perhaps,  best,  and  ela- 
terium  or  salines  come  next  in  efficiency. 

Erysipelas. — Da  Costa  reports  suc- 
cess from  the  use  of  pilocarpine  in  acute 


erysipelas.  He  recommends  the  hypo- 
dermic administration  of  1/Q  grain  every 
three  hours  until  free  sweating  ensues, 
then  every  four  to  six  hours.  Its  action 
is  so  prompt  and  effective  that  it  may 
almost  be  regarded  as  a  specific.  The 
diaphoresis  is  at  once  followed  by  the 
retrocession  of  the  rash,  and  an  improve- 
ment in  the  general  condition.  In  atonic 
cases,  when  the  heart  is  weak  and  per- 
spiration cannot  be  established  by  pilo- 
carpine no  beneficial  action  is  observed 
(Waugh). 

Hypodermic  injections  of  pilocarpine 
recommended  in  facial  erysipelas. 
Twenty-four  cases  treated  in  this  man- 
ner, all  severe,  20  presenting  albumi- 
nuria and  4  retention  of  urine.  The 
drug  must  be  administered  until  the 
physiological  effects  are  produced.  Re- 
covery took  place  in  all  his  cases  within 
eight  days  at  latest,  and  in  some  cases  in 
four  days.  Pilocarpine  is  contra-indi- 
cated in  affections  of  the  heart.  If  the 
erysipelas  appear  as  a  complication,  the 
treatment  is  absolutely  without  efficacy. 
Salinger  (Ther.  Gaz.,  Mar.  15,  '94). 

Good  results  with  the  drug  in  erysipe- 
las; its  efficacy  probably  depends  on  the 
time  which  has  elapsed  from  the  incep- 
tion of  the  first  symptoms  before  treat- 
ment is  begun.  In  cases  seen  very  early 
success  is  almost  invariable.  G.  W.  Barr 
(Ther.  Gaz.,  May  15,  '94). 

Fevers. — A  dose  of  pilocarpine  will 
generally  succeed  in  aborting  a  malarial 
chill.   It  should  not  be  used  in  asthenia. 

Acute  Congestion.  —  In  the  acute 
congestive  conditions  following  fevers  or 
exposure  to  cold  —  coryza,  bronchitis, 
laryngitis,  muscular  or  articular  rheuma- 
tism, and  similar  affections — pilocarpine 
may  be  used  with  benefit  in  the  early 
stage.  Small  doses  of  pilocarpine  fol- 
lowed by  quinine  are,  perhaps,  as  effi- 
cient as  large  doses  and,  withal,  safer. 

Jaborandi  will  arrest  pneumonia  in 
three  or  four  days  if  it  is  administered  in 
t lie  congestive  stage  and  free  diaphoresis 


THERAPEUTICS. 


238  JABORANDI. 

is  seemed.  A  temperature  of  105°  F.  in 
congestion  of  the  lungs  has  repeatedly 
been  reduced  to  a  temperature  of  99.5°  F. 
within  twenty-four  hours  by  the  use  of 
jaborandi.  J.  B.  Carrell  (Med.  and  Surg. 
Reporter,  Jan.  12,  '89). 

In  parotitis  (mumps)  the  relief  from 
pilocarpine  is  prompt  when  given  early. 

Chronic  Affections. — Chronic  rheu- 
matic disorders  and  sciatica  have  been 
ameliorated  by  diaphoretic  doses  of  pilo- 
carpine. 

In  a  patient  who  suffered  from  two  or 
three  attacks  of  rheumatism  yearly,  the 
writer  used  hypodermic  injections  of 
pilocarpine,  using  l/8  gram,  which  led  to 
complete  recovery  within  six  days.  Drap- 
pier  (Jour,  des  Sci.  Med.  de  Lille,  Sept. 
15,  '94). 

The  fulgurant  pains  of  locomotor 
ataxia  may  sometimes  be  relieved  by 
subcutaneous  injections  of  pilocarpine. 
Mitkowski  has  tried  pilocarpine  in  per- 
sistent catarrhal  jaundice  with  great 
benefit,  in  the  hypodermic  dose  of  1/6 
grain  every  other  day  for  three  weeks. 
He  attributes,  moreover,  a  diagnostic 
value  to  the  procedure.  If  the  above 
treatment  produces  no  effect  upon  the 
jaundice,  the  presence  of  a  malignant 
growth  is  to  be  suspected. 

In  laryngitis  with  scanty  secretion  J. 
Solis-Cohen  suggests  the  use  of  from  1 
to  5  minims  of  the  fluid  extract  of  jabo- 
randi to  1  ounce  of  water,  in  spray 
locally. 

Pilocarpine  is  a  specific  for  croup  and 
all  croupous  diseases.  Its  action  begins 
at  once.  The  drug  can  be  given  by  the 
mouth,  subeutaneously,  or  in  supposi- 
tory. The  duration  of  the  disease  is 
notably  shortened  by  the  use  of  pilo- 
carpine and  the  mortality  reduced  to  nil. 
The  daily  doses  advised  are  as  follow: 
Up  to  1  year,  '/,.  to  l/a  grain:  1  to  3 
years,  Vs  to  7_>  grain;  3  to  6  years,  2/.t 
grain;  6  to  10  years,  7/s  grain:  10  to  15 
years.  1  to  1  Vs  grains:  adults.  1  '/4 
grains  to  15 V2  grains.  Sziklai  (Wiener 
med.  Woch.,  Nos.  32,  33.  '94). 


In  bronchitis  with  asthma,  in  winter- 
cough,  and  in  hiccough  jaborandi  has 
proved  of  great  benefit. 

Patient  whom  obstinate,  continuous 
hiccough  had  brought  very  low,  and  for 
whom  many  therapeutic  measures  had 
been  employed  without  relief.  Prompt 
success,  however,  followed  the  adminis- 
tration of  a  decoction  of  jaborandi. 
Kuthe  (Med.  and  Surg.  Reporter,  Apr. 
21,  '88). 

Cutaneous  Disorders. — In  skin  dis- 
eases characterized  by  a  deficient  secre- 
tion of  the  sweat-glands  and  in  those  of 
rheumatic  origin,  jaborandi  has  proved 
efficient.  In  chronic  eczema  Koltz  has 
obtained  favorable  results  from  hypo- 
dermic injections  of  10  to  15  drops  of 
a  1-per-cent.  solution  of  pilocarpine. 
Poulet  suggests  that  the  same  procedure 
may  be  of  service  in  the  treatment  of 
elephantiasis  arabum.  Jaborandi  has 
alleviated  urticaria,  and  doses  of  1/20 
grain  have  proved  remedial  in  hyperi- 
drosis  and  bromidrosis. 

Pruritus  is  not  uncommonly  relieved 
by  this  agent.  The  itching  of  jaundice 
is  amenable  to  pilocarpine  if  the  drug 
is  well  borne  and  diaphoresis  ensues. 

K.  M.  Simon,  of  Birmingham,  finds 
nothing  so  useful  as  pilocarpine  hypo- 
dermic-ally in  the  treatment  of  pruritus 
senilis.  It  relieves  the  itching  and  allows 
the  patient  to  sleep.  In  alopecia  the  use 
of  jaborandi  internally — or,  better,  ap- 
plied locally — encourages  the  growth  of 
the  hair.  If  too  much  is  used,  small 
pustules  may  develop  about  the  hair- 
follicles.  Bartholow  suggests  the  follow- 
ing in  cases  of  alopecia: — 

Jy  Fluid  extract  of  jaborandi.  1  ounce. 
Tincture  of  cantharides,  1  8  ounce. 
Soap-liniment,  1  1/2  ounces. 
Mix  and   apply  night   and  morning 
with   friction.     For  the  same  purpose 
Hare  suggests  the  use  of: — 


JABORANDI.  THERAPEUTICS. 


239 


1^  Fluid    extract    of    jaborandi,  1 
drachm. 

Tincture  of  capsicum,  1  ounce. 
Tincture     of     cantharides,  1/2 

drachm. 
Castor-oil,  1  drachm. 
Alcohol,  enough  to  make  P  ounces. 

Deficient  Glandular  Secretion. 
— Dryness  of  the  tongue  and  aptyalism 
may  be  relieved  by  small  doses  (V200  to 
V100  grain)  of  pilocarpine.  The  dryness 
of  the  mouth  often  so  troublesome  in 
diabetes  mellitus  is  relieved  in  the  same 
manner. 

In  the  agalactia  of  nursing  women, 
small  doses  of  pilocarpine  restore  the 
secretion  of  milk. 

Ophthalmic  Disorders.  —  Pilocar- 
pine is  useful  in  all  disorders  of  the  eye 
associated  with  increased  ocular  pressure. 
De  Schweinitz  recommends  very  highly 
the  hypodermic  use  of  pilocarpine  (1/12 
to  V10  grain  daily)  for  opacities  of  the 
vitreous  humor.  Diaphoresis  should  be 
avoided.  As  a  myotic  (1  to  4  grains  to 
the  ounce)  it  is  rapidly  taking  the  place 
of  eserine;  1  or  2  drops  every  hour  may 
be  used  until  the  patient  is  relieved. 
Pilocarpine  is  useful  as  a  tonic  to  the 
eye;  to  relieve  eye-pain  after  excessive 
use  of  the  eyes  use  1/10  grain  of  pilo- 
carpine and  4  grains  of  boric  acid  to  the 
ounce  of  distilled  water,  a  few  drops  of 
the  solution  being  dropped  into  the  eye 
three  times  daily  (Hare).  Clinical  re- 
ports show  that  pilocarpine  in  small 
doses  is  a  very  good  remedy  in  tobacco- 
amblyopia  and  alcoholic  amblyopia. 
Burnham,  of  Toronto,  reports  the  good 
effects  of  the  remedy  in  a  case  where  the 
centre  of  each  cornea  was  studded  with 
infiltrations;  the  pupillary  area  was  in- 
volved and  vision  was  imperfect.  A  few 
drops  of  a  2-grain  solution  of  pilocarpine 
may  be  employed  locally  with  advantage 
in  rheumatic  iritis.     Staderini  advises 


pilocarpine  nitrate  (V8  'to  1/10  grain) 
hypodermically,  in  many  inflammatory 
diseases  of  the  eyes,  especially  in  those 
consequent  upon  rheumatism,  as  epi- 
scleritis, iritis,  and  idiopathic  optic  neu- 
ritis. 

Good  results  from  injections  of  small 
amounts  (2  to  3  centigrammes)  of  con- 
centrated solutions  of  pilocarpine  in  cases 
of  blood  in  the  anterior  chamber,  and  in 
vitreous  opacities  after  iridocyclitis  and 
choroiditis  without  general  disease.  Bock 
(Centralb.  f.  die  gesammte  Ther.,  Mar., 
'88). 

Literature  of  '96-'97-'98. 

In  the  treatment  of  conditions  of  the 
eye  and  ear  in  which  jaborandi  is  thought 
to  be  useful,  it  is  probably  better  to  ad- 
minister the  alkaloid  pilocarpine  hypo- 
dermically rather  than  to  employ  the  in- 
fusion.   Laval  (Ther.  Gaz.,  Sept.  15,  '97). 

Aural  Vertigo. — In  cases  of  obsti- 
nate aural  vertigo  a  most  efficient  treat- 
ment is  the  use  of  pilocarpine  every  few 
days  in  sufficient  doses  to  produce  some 
salivation,  the  patient  lying  down  or 
going  to  bed  after  each  dose. 

Three  cases  of  Meniere's  disease  in 
which  the  hypodermic  use  of  pilocarpine 
gave  satisfactory  results.  The  medica- 
ment was  given  in  daily  doses  of  from 
V25  to  V4  grain.  These  injections  were 
generally  followed  by  sialorrhcea  and  pro- 
fuse diaphoresis.  Labit  (Revue  de 
Laryn.,  d'Otol.,  et  de  Rhin.,  Sept.  1,  '94). 

Antidote  to  Atropine. — Although 
atropine  is  a  very  efficient  antidote 
against  poisoning  by  pilocarpine,  pilo- 
carpine is  less  potent  as  an  antidote  in 
poisoning  from  atropine.  However,  Mc- 
Gowan  relates  a  case  in  which  two  in- 
jections of  1/2  grain  each  were  undoubt- 
edly 1he  means  of  saving  the  life  of  a 
patienl  suffering  from  belladonna  poison- 
ing. The  same  procedure  is  recom- 
mended as  beneficial  in  acute  alcoholism. 
Patienl  quickly  brought  out  of  a  con- 
dition of  alcoholic  coma  by  tlu>  adminis- 


240  JALAP. 

tration  of  pilocarpine  and  a  hot-air  bath. 
G.  W.  Davis  (Kansas  City  Med.  Index, 
Nov.,  '88). 

C.  Sumner  Witherstine, 

Philadelphia. 

JACKSONIAN  EPILEPSY.  See  Epi- 
lepsy. 

JAIL-FEVER.    See  Typhus  Fever. 

JALAP.  —  Jalap  (Jalapa,  U.  S.  P.), 
named  from  Jalapa,  a  city  of  Mexico,  is 
the  dried  tuberous  root  of  the  Ipomcea 
Jalapa  {Exogonium  purga  or  Ipomcea 
pur  go),  one  of  the  Convolvulacece,  which 
is  indigenous  to  Mexico.  The  root  has 
a  peculiar  smoky  odor,  and  an  acrid, 
sweetish,  and  nauseous  taste.  As  seen  in 
the  shops,  it  is  usually  in  a  yellowish- 
gray  powder.  The  active  principle  ol 
jalap  is  found  in  a  double  resin  in 
amounts  varying  from  12  to  18  per  cent,, 
which  is  divisible  into  two  portions:  one 
(convolvulin)  of  which  is  hard  and  in- 
soluble in  ether,  but  soluble  in  alcohol 
and  chloroform  and  partly  soluble  in 
water;  the  other  (jalapin)  is  soft  and 
soluble  in  ether  and  alcohol.  Both  are 
active  purges,  but  convolvulin  is  more 
potent  (dose,  1  to  3  grains)  than  jalapin 
(dose,  2  to  5  grains).  Jalap  also  contains 
about  18  per  cent,  each  of  starch  and 
sugar.  According  to  Poleck,  jalapin  is  a 
resinous  glucoside,  separable  by  the 
action  of  hydrochloric  acid  into  sugar 
and  jalapinolic  acid,  and  identical  with 
scammonin. 

Preparations  and  Doses. — -Jalapa,  10  to 
30  grains. 

Extractum  jalapae,  2  to  5  grains. 

Pulvis  jalapae  compositus  (jalap,  35; 
cream  of  tartar,  65  parts),  10  to  60 
grains. 

Resina  jalapae,  2  to  5  grains. 
Physiological  Action. —  Beyond  the 
fact  that  jalap  acts  as  a  powerful  hvdra- 


JAMBUL. 

gogic  cathartic,  and  that  gastrointes- 
tinal irritation  is  produced  by  an  over- 
dose, little  is  known  concerning  the 
effects  of  this  drug.  It  is  also  irritating 
when  applied  to  the  mucous  membrane. 
According  to  Vulpian  and  Moreau,  when 
applied  to  the  exposed  colon  it  gives  rise 
to  active  peristaltic  motion.  Jalap 
passes  into  the  milk  of  wet-nurses  and 
purges  their  nurslings. 

Poisoning  by  Jalap.  —  Jalap  when 
taken  in  overdose  acts  as  a  simple  irri- 
tant poison  to  the  alimentary  canal,  the 
symptoms  being  copious  watery  stools, 
tormina,  and  tenesmus.  The  treatment 
of  poisoning  consists  in  the  evacuation 
of  the  retained  jalap  by  the  stomach- 
pump  and  the  use  of  demulcent  drinks. 

Therapeutics.  —  Jalap  is  used  prin- 
cipally as  an  hydragogic  purge  to  relieve 
dropsical  effusions,  anasarca,  and  ascites. 
The  resin,  being  the  active  constituent 
(containing  both  convulvulin  and  jala- 
pin), should  generally  be  preferred.  As  it 
is  almost  tasteless  and  the  dose  small,  it 
may  be  readily  given  to  children  in  doses 
of  V4  to  1/2  grain.  Jalap  is  contra-indi- 
cated in  inflammatory  states  of  the  in- 
testinal canal.  Combined  with  calomel, 
it  is  probably  the  best  purge  in  cases 
where  the  liver  is  torpid.  The  compound 
jalap  powder  is  most  often  used  as  an 
hydragogic  cathartic  for  dropsy,  either 
of  cardiac  or  renal  origin.  In  pulmonary 
congestion  and  distended  right  heart 
with  cyanosis,  dyspnoea,  and  so-called 
cardiac  asthma,  a  teaspoonful  of  com- 
pound jalap  powder  will  give  relief.  In 
haemorrhoids  it  does  not  cause  irritation, 
but  relieves  them  by  emptying  the  ves- 
sels above,  and  clearing  out  the  liver. 

JAMBUL. — Jambul  is  a  tree  that 
grows  in  most  tropical  climates,  and  be- 
longs to  the  Myrtacece.  It  is  the  Eugenia 
jambolana  of  Lamk  or  the  Syzygium  jam- 


JAMBUL.    PHYSIOLOGICAL  ACTION. 


241 


bolana  of  de  Candalle.  From  the  fruits, 
by  alcoholic  fermentation,  a  liquor  is  ob- 
tained, the  jambava  of  the  Hindoos. 
This  liquor,  allowed  to  acidify,  turns  into 
a  vinegar,  of  an  agreeable  taste,  and  is 
extensively  used  by  them  as  a  stomachic, 
carminative,  and  diuretic. 

Three  varieties  of  jambul  grow  in 
India,  and  the  ripe  fruit  can  be  eaten  in 
season;  at  other  times  the  fruit  pre- 
served in  spirit  can  be  employed.  The 
powdered  seed  in  doses  of  about  5  to  10 
grains  three  times  a  day  is  recommended 
as  a  very  effective  means  of  administra- 
tion. A  vinegar  of  a  light-pink  color  can 
be  prepared  by  exposing  the  juice  of  the 
ripe  fruit,  contained  in  porcelain  vessels, 
to  the  heat  of  the  sun;  after  the  juice  has 
commenced  to  ferment  it  is  filtered  and 
again  set  in  a  warm  place  for  a  fortnight, 
when  it  is  ready  for  use.  The  best  form 
is  either  the  whole  fruit  preserved  in  al- 
cohol, the  powdered  seed,  or  a  fluid  ex- 
tract of  the  seeds.  The  pulp  of  the  dried 
fruit  is  believed  to  be  almost  worthless. 

Literature  of  '96-'97-'98. 

To  obtain  the  seed  fit  for  use  it  is 
necessary  that  the  tree  from  which  it  is 
gathered  should  be  of  the  right  variety 
of  jambul,  and  that  no  "wind-falls"  or 
rotten  fruit  be  included.  The  native  phy- 
sicians believe  that  this  remedy  is  of  the 
greatest  use  in  the  treatment  of  diabetes, 
and  that  there  is  no  necessity  to  restrict 
the  patient's  diet,  as  this  prevents  the  pos- 
sibility of  the  excretion  of  sugar  in  the 
urine.   Rudolf  (Bull.  Pharm.,  No.  1,  '98). 

Preparations  and  Dose. — The  prepa- 
ration generally  employed  is  the  powder, 
which  may  be  given  in  doses  varying 
from  8  grains  to  1  drachm. 

A  II ii id  extract  is  more  conveniently 
administered,  and  can  be  given  in  graded 
doses  from  10  to  30  minims,  according 
to  the  results  obtained,  in  emulsion  or 
capsules. 

4- 


Physiological  Action. — The  manner  in 
which  the  reduction  of  sugar  in  diabetic 
urine  occurs  when  this  agent  is  adminis- 
tered is  not  known,  no  untoward  results 
having  been  noted  in  any  case  that  could 
give  a  clue  to  its  action.  It  acts  as  a 
gastric  tonic  through  a  principle  that  re- 
sides in  the  seeds,  the  bark,  and  the  fruit 
of  the  plant. 

Its  properties,  however,  are  principally 
in  the  seeds,  wdiich,  according  to  the 
latest  analyses,  especially  that  of  Elborne, 
contain  essential  oil,  chlorophyl,  resin, 
gallic  acid,  albumin,  coloring  extracts, 
and  an  insoluble  residue.  These  grains 
appear  to  contain  an  active  principle,  a 
glucoside,  to  which  the  physiological 
effects  of  the  plant  are  due,  but  which, 
as  yet,  has  not  been  isolated. 

Von  Mehring  has  shown  that  phlorid- 
zin,  a  glucoside  extracted  from  the  apple- 
tree,  the  pear-tree,  and  other  plants,  has 
the  power  of  producing  sugar  in  the 
urine  of  animals.  Groeser  instituted  a 
series  of  experiments  upon  animals,  and 
administered  phloridzin  to  dogs  in  the 
proportion  of  15  grains  per  2  1/2  pounds 
of  body-weight,  and  was  able  to  produce 
a  considerable  amount  of  glycosuria, 
which  persisted  from  twenty-four  to 
thirty-nine  hours.  It  was  also  found  that 
phloridzin  caused  diarrhoea.  Assured  of 
the  effects  of  this  glucoside,  the  experi- 
menter then  submitted  the  dogs  to  the 
conjoined  action  of  phloridzin  and  the 
extract  of  jambul,  and  found  that  under 
such  circumstances  the  sugar  of  the  urine 
was  invariably  diminished  almost  to  one- 
half  of  that  secreted  under  the  action  of 
the  phloridzin  alone,  and  also  that  the 
duration  of  the  glycosuria  was  consider- 
ably lessened.  In  pushing  his  experi- 
ments in  order  to  determine  the  toxicity 
of  jambul,  Groeser  noticed  that  as  many 
as  5  drachms  of  the  drug  could  be  given 
in  a  day  without  producing  in  the  dog 
16 


242 


JAMBUL.  THERAPEUTICS. 


any  deleterious  effects,  with  the  excep- 
tion of  some  diarrhoea.  (Egasse.) 

Therapeutics. — The  juice  of  the  fresh 
bark,  mixed  with  goats'  milk,  is  said  to  be 
used,  in  the  treatment  of  infantile  diar- 
rhoea. It  has  also  been  used  as  an  as- 
tringent in  the  form  of  gargles  and  lo- 
tions. 

Diabetes. — The  plant  has  been  espe- 
cially extolled  in  the  treatment  of  dia- 
betes. The  natives  of  India  and  the  Eng- 
lish physicians  were  the  first  to  speak  in 
favor  of  jambul  as  a  remedy  for  diabetes 
mellitus.  The  experiments  of  Lascelles 
Scott,  T.  A.  E.  Balfour,  and  G.  Sims 
Woodhead  show  that  jambul  has  the 
power  to  stop,  in  a  marked  degree,  the 
conversion  of  starch  into  sugar,  and  that 
this  action  increases  proportionately  to 
the  quantity  of  the  drug  used. 

Following  the  results  of  the  experi- 
ments of  von  Mering,  clinicians  have  em- 
ployed jambul,  with  varying  success,  in 
the  treatment  of  diabetes  in  man.  Egasse 
has  shown  that  the  drug  can  apparently 
do  good  only  in  the  mild  forms  of  dia- 
betes, but  in  which  kind  of  diabetes  it 
will  do  the  most  good  has  not  yet  been 
determined.  The  facts  so  far  collected 
point  to  the  insipidus  form.  The  drug 
has  been  employed  mostly  in  the  form  of 
powder.  The  minimum  dose  may  be  set 
down  as  from  4  to  7  grains,  repeated 
three  or  four  times  a  day.  but  it  can  be 
increased  to  even  1  1/2  drachms  in  the 
twenty-four  hours,  according  to  the  re- 
quirements of  the  individual  cases. 

Case  of  a  man,  65  years  of  age,  who,  in 
spite  of  a  diabetic  regime,  continued  to 
present  all  the  symptoms  of  a  wcll- 
developed  glycosuria.  Before  the  drug 
was  administered  the  patient  weighed 
175  pounds,  and  every  twenty-four  hours 
he  would  pass  5 1/2  pints  of  urine  of  a 
specific  gravity  of  10,38.  of  a  yellowish 
green  color,  of  an  acid  reaction,  and  con- 
taining 4  ounces  of  sugar.  After  a 
month's  treatment  the  specific  gravity  of 


the  urine  was  1038;  this  was  reduced  to 
3  V?  pints  every  twenty-four  hours,  and 
the  quantity  of  the  urine  lowered  to  2  1/4 
ounces.  In  seven  more  days  the  sugar 
was  increased  to  3  ounces,  and  the  results 
in  general  were  little  satisfactory.  In 
three  more  weeks  the  patient  had  lost  1 
pound  in  weight,  and  both  the  quantity 
of  the  fluid  and  the  amount  of  sugar 
continued  to  increase.  The  patient  was 
again  subjected  to  a  diabetic  diet  and  the 
powder  of  jambul  in  appropriate  doses, 
but  the  ultimate  results  continued  to  be 
negative.  The  author,  however,  at- 
tributes the  failure  to  the  advanced  age 
of  the  patient,  which,  in  itself,  made  the 
case  a  rebellious  one.  A.  E.  Balfour 
(New  Commercial  Plants  and  Drugs,  No. 
11,  '89). 

Jambul  in  doses  of  2  1/2  to  3  grains  in 
pills  three  times  a  day  diminishes  the 
amount  of  urine  and  the  percentage  of 
sugar  in  diabetes,  while  sloughing  ulcers 
attending  the  disease  healed  with  sur- 
prising rapidity.  In  simple  polyuria  no 
effect  was  noticeable.  H.  Fenwick  (Med. 
Standard,  Feb.,  '88). 

Four  cases  of  diabetes  treated  with  the 
drug,  beginning  with  a  dose  of  5  grains 
and  increasing  to  15  grains  three  times  a 
day,  but  without  the  slightest  benefit. 
T.  Oliver  (Lancet,  May  5,  '88). 

Three  cases  of  marked  glycosuria 
treated  with  jambul.  In  two  cases  the 
drug  was  employed  in  the  form  of  pow- 
der, in  doses  of  15  grains  three  or  four 
times  a  day,  during  twelve  consecutive 
days.  In  the  third  instance  the  same 
amount  was  administered  in  the  same 
manner  for  one  hundred  and  forty-seven 
days,  but  no  good  results  followed. 
Javeine  (Wratsch,  No.  47,  '89). 

Two  cases  of  diabetes  in  which  jambul 
was  employed.  Success  was  observed  in 
the  first  case.  In  the  second  instance  the 
drug  proved  wholly  inefficacious.  •'.  A. 
danger  and  H.  Vandenberg  (Neder- 
landsch  Tyd.  voor  Cenees..  vol.  ii.  Xo.  1. 
'00). 

Extract  of  jambul  used  in  the  treat- 
ment of  glycosuria,  the  rind  being  used 
instead  of  the  fruit  in  the  preparation. 
This  makes  it  more  agreeable  in  taste 
and  much  cheaper  than  the  fruit.  As 
much  as  1  l/s  ounces  per  day  can  be  ad- 


JAUNDICE,  OBSTRUCTIVE.  SYMPTOMS. 


243 


ministered  for  a  long  period  without  dis- 
agreeable effects.  It  is  best  given  in 
water  or  wine.  Vix  (Therap.  Monats., 
Apr.,  '93). 

JAUNDICE  (ICTERUS). 

Definition. — This  is  not  a  disease,  but 
only  a  symptom-group,  occurring  under 
a  variety  of  conditions  and  characterized 
by  a  yellowish  discoloration  of  the  skin, 
tissues,  and  fluids  of  the  body  with  bile- 
pigment,  and  the  excretion  of  the  pig- 
ment in  the  urine. 

It  has  been  customary  to  classify  all 
cases  of  jaundice  into  the  two  great 
groups  of  obstructive  and  non-obstruct- 
ive jaundice,  but,  the  more  thoroughly 
the  pathology  of  the  condition  is  investi- 
gated, the  greater  is  the  number  of  non- 
obstructive cases  that  are  found  in  reality 
to  be  obstructive,  and  in  time  it  is  prob- 
able that  in  all  conditions  jaundice  will 
prove  to  be  obstructive  in  origin. 

William  Hunter,  in  "Allbutt's  System 
of  Medicine,"  designates  the  two  groups 
of  jaundice  as  obstructive  and  toxaemic; 
these  seem  to  be  the  most  suitable  terms 
at  present  available.  The  obstructive 
group  includes  all  cases  dependent  on 
palpable  obstruction;  and  the  toxaemic 
those  occurring  in  connection  with  some 
general  infection. 

Jaundice  resulting  from  mental  emo- 
tion, usually  of  a  depressing  nature,  can- 
not be  placed  in  either  group;  its  nature 
is  quite  uncertain. 

A  nervous  origin  of  many  cases  of 
jaundice  maintained.  Rockwell  (N.  Y. 
Med.  Jour.,  Dec.  10,  '92). 

Case  of  jaundice  due  to  emotion.  It 
occurred  in  a  woman  of  24  years,  ap- 
parently not  neurotic,  and  manifested 
itself  five  or  six  hours  after  the  nervous 
shock.  Talamon  (La  Med.  Mod.,  Aug. 
23,  '03). 

Case  of  jaundice  developed  after  an  in- 
strumental delivery  in  a  highly-sensitive 
young  woman.  E.  A.  Lubbock  (Brit. 
Med.  Jour.,  Apr.  21,  '04). 


Three  cases  noted  in  which  jaundice 
supervened  in  children  of  nervous  di- 
athesis after  emotional  excitement. 
Coulon  (Brit.  Med.  Jour.,  May  19,  '94). 

Two  kinds  of  emotional  jaundice  dis- 
tinguished: that  coming  on  in  a  short 
time  and  passing  off  very  quickly,  and 
that  in  which  the  onset  is  slow  and  the 
course  more  protracted.  The  former  is 
due  to  an  immediate  reflex  dilatation  of 
the  vessels  of  the  abdomen  and  contrac- 
tion of  the  biliary  vessels,  as  a  result  of 
which  the  bile  finds  its  way  in  the  direc- 
tion of  the  lesser  resistance  into  the 
blood.  The  other  form  is  due,  in  the  first 
place,  to  nervous  atony  of  the  intestinal 
walls  and  glands,  as  a  result  of  which 
catarrhal  inflammation  is  prone  to  occur 
and  to  extend  into  the  biliary  vessels. 
Potain  (Union  Med.,  No.  70,  '94). 

Jaundice  from  suppression  of  liver- 
function  cannot  now  be  accepted  as  pos- 
sible, as  bile-pigment  can  only  occur  as 
the  result  of  hepatic  cell-activity.  Fur- 
ther, the  removal  of  the  liver  or  the  com- 
plete severance  of  its  connections  by  liga- 
ture does  not  cause  jaundice. 

I.  Obstructive  Jaundice  (Hepatoge- 
nous Jaundice ;  Extrahepatic  Jaundice) . 

General  Symptoms. — The  color  of  the 
skin  varies  according  to  the  intensity  and 
duration  of  the  jaundice.  In  cases  of 
catarrhal  jaundice  with  sudden  obstruc- 
tion the  surface  becomes  rapidly  stained 
a  deep  yellow.  When  jaundice  has  ex- 
isted for  a  considerable  time  it  changes 
to  a  greenish  hue,  which  gradually  passes 
into  a  dark-olive  color,  doubtless  on  ac- 
count of  the  action  of  the  air  on  the  bile- 
pigment  in  the  skin.  This  very  dark 
color  known  as  "black  jaundice,"  though 
not  pathognomonic  of  cancer  in  the  liver, 
is  rarely  produced  by  any  other  disease. 
The  icteric  line  shows  most  distinctly  on 
the  pallid  parts  and  to  a  much  less  degree 
on  highly-colored  parts,  as  the  lips,  florid 
cheeks,  mucous  membrane  of  the  mouth, 
etc.   We,  therefore,  look  to  the  conjune- 


244 


JAUNDICE,  OBSTRUCTIVE.  SYMPTOMS. 


tivge  for  the  first  signs  of  icteric  discolor- 
ation. 

Series  of  experiments  on  dogs  leading 
to  the  following  conclusions:  1.  Contrary 
to  accepted  pathological  doctrine,  the  bile 
which  is  eliminated  by  the  urine  and 
deposited  in  the  skin,  in  cases  of  ob- 
structive jaundice,  does  not  find  its  way 
into  the  general  circulation  through 
being  absorbed  by  the  blood-capillaries. 

2.  It  is  the  lymphatic  system  of  vessels 
alone  which  absorbs  the  biliary  matters 
in  obstructive  jaundice,  and  it  is  through 
the  instrumentality  of  the  thoracic  duct 
that  they  reach  the  general  circulation. 

3.  After  the  thoracic  duct  has  been  liga- 
tured for  some  days,  supplementary  ducts 
form  by  the  coalescence  of  either  entirely 
new  or  pre-existing,  small,  collateral 
lymphatics  from  the  thoracic  duct,  at  a 
point  below  the  seat  of  ligature,  through 
which  its  lymph-stream  passes  vicari- 
ously into  the  right  innominate  vein.  4. 
After  the  common  bile-duct  is  ligatured, 
the  whole  of  the  constituents  of  the  pent- 
up  bile  do  not  become  equally  concen- 
trated, the  less  soluble,  such  as  choles- 
terin  and  mucin,  being  by  far  the  most 
concentrated.  5.  From  the  dogs  experi- 
mented on  having,  in  many  cases,  not 
only  lived,  but  even  gained  in  weight, 
after  bile  was  prevented  from  finding  its 
way  into  the  duodenum,  it  may  be  in- 
ferred that  the  admission  of  bile  into  the 
digestive  canal  is  not  absolutely  essential 
to  life.  (i.  Ligaturing  the  thoracic  duct 
not  only  prevents  the  occurrence  of  ob- 
structive jaundice,  after  the  occlusion  of 
the  common  bile-duct  in  dogs,  but  checks 
it  even  after  it  has  set  in.  Vaughan 
Harley  (Brit.  Med.  Jour..  Aug.  20,  '92). 

Literature  of  '98-'97-'98. 

By  the  aid  of  injected  and  safranin- 
stained  microscopical  liver  preparations 
the  following  facts  demonstrated:  1.  The 
seeretion-vacuoles  of  the  liver  discovered 
by  Kopffer  do  not  form  the  terminals  of 
the  bile-channels,  but  the  Liver-cells  are 
filled  with  a  fine  canal-reticulum  sur- 
rounding the  nucleus;  this  reticulum 
is  continuous  with  the  intercellular  bile- 
capillaries.  2.  An  injection  of  the  liver 
cells  is  possible  by  way  of  the  blood 
vessels,  since  a  dense  net-work  of  blood-  I 


capillaries  surrounds  the  nuclei  of  the 
liver-cells.  From  these  results  the  new 
theory  submitted  in  reference  to  conges- 
tion-jaundice: In  entering  the  blood- 
channels  it  is  not  necessary  that  the  bile 
should  go  by  the  route  of  the  thoracic 
duct;  admission  to  the  blood  may  occur 
in  the  liver-cells  themselves  by  diffusion 
from  the  bile-capillaries  surrounding  the 
nuclei  into  the  neighboring  blood-capil- 
laries. C.  Nauwerck  (Munch,  med. 
AVoch.,  xliv,  2). 

Many  of  the  secretions  are  also  colored 
with  bile-pigment.  The  sweat  is  yellow 
and  stains  the  patient's  linen.  The  tears 
and  milk  may  also  be  colored,  but  the 
saliva  is  not  stained  nor  do  the  secretions 
of  the  mucous  membra  ties,  not  even  of 
the  bile-ducts  and  gall-bladder,  contain 
any  bile. 

Inflammatory  exudates,  as  the  sputa  of 
pneumonia,  are  bile-stained,  as  are  also 
the  exudates  into  the  various  serous 
cavities. 

Since  the  removal  of  diffusible  sub- 
stances in  the  blood  is  chiefly  by  the  kid- 
neys, it  follows  that  the  urine  contains 
more  of  the  biliary  coloring  matter  than 
any  other  secretion.  It  may  be  present 
in  the  urine  before  it  appears  in  the  con- 
junctiva even.  The  color  of  the  urine 
may  vary  from  a  barely  perceptible 
greenish-yellow  to  a  dark-brown  or  even 
black  color.  Bile-pigment  is  invariably 
present  in  the  urine  in  jaundice,  except 
in  chronic  cases  in  which  the  obstruction 
to  the  bile-flow  is  suddenly  removed, 
when  the  icteric  hue  of  the  skin  will  per- 
sist after  the  blood  has  been  cleared  of 
the  bile-pigment.  Bile-stained  urine 
foams  readily  when  shaken,  and  the  froth 
is  of  a  yellow  color.  Rhubarb  and  san- 
tonin, when  administered,  produce  a 
similar  color  in  the  urine,  but  the  froth 
is  not  yellow;  the  addition  of  caustic 
potash  causes  a  red  coloring  of  the  fluid 
and  the  tests  for  bile-pigments  are  not 
obtained. 


JAUNDICE,  OBSTRUCTIVE.  SYMPTOMS. 


245 


Gmelin's  test  is  usually  employed  to 
determine  the  presence  of  bile-pigment, 
but  it  may  fail  to  give  a  reaction  even  in 
the  presence  of  5  per  cent,  of  bile.  It  is 
best  made  by  placing  a  few  drops  of  com- 
mon nitric  acid  and  of  the  urine  on  a 
white,  flat  surface  and  then  causing  them 
to  run  together.  A  play  of  colors  results 
at  the  margin  of  contact,  rapidly  passing 
through  various  shades  of  green,  blue, 
violet,  and  red,  finally  becoming  a  dirty 
yellow. 

The  following  modification  of  it  is 
much  more  delicate,  revealing  even  0.2 
per  cent,  of  bile,  and  should  be  employed 
in  doubtful  cases:  "To  50  cubic  centi- 
metres of  urine  add  5  cubic  centimetres 
of  10-per-cent.  barium-chloride  solution 
and  5  cubic  centimetres  of  chloroform. 
Shake  for  several  minutes.  Set  aside  for 
ten  minutes.  The  chloroform  and  pre- 
cipitate of  phosphates  fall  down,  carry- 
ing with  them  all  the  bile-pigment.  Now 
draw  off  the  chloroform  and  the  precipi- 
tate with  a  pipette.  Place  in  a  flat  dish, 
and  set  over  a  basin  of  hot  water  until  all 
the  chloroform  has  evaporated.  Allow  to 
cool  and  pour  off  any  fluid  from  the  pre- 
cipitate. The  latter  will  be  yellowish. 
Place  impure  nitric  acid  in  drops  here 
and  there  on  the  surface  of  the  precipi- 
tate. If  bile-pigment  is  present  a  play 
of  colors  appears  round  each  drop." 
("Clinical  Methods,"  by  Hutchinson  and 
Rainy.) 

The  stained  cellular  elements  in  the 
urine  afford  a  reliable  test  for  the  pres- 
ence of  bile-pigment.  In  chronic  cases 
the  urine  may  contain  albumin  and  pig- 
mented tube-casts. 

In  some  cases  of  jaundice  at  least  the 
urine  is  diminished  in  amount  during  the 
attack.  By  the  tenth  or  twelfth  day 
there  is  a  crisis,  with  large  excretion  of 
urine  and  a  corresponding  increase  in 
urea.  Chauffard  (Revue  de  Med.,  Sept., 
'87 ). 


In  ordinary  jaundice  the  color  of  both 
skin  and  urine  is  due  to  bilirubin.  Leube 
(Centralb.  f.  klin.  Med.,  Nov.  30,  '90). 

In  those  slight  forms  of  jaundice  in 
which  bile-pigments  do  not  appear  in  the 
urine  in  appreciable  quantity  the  spec- 
troscope furnishes  a  very  delicate  and  ac- 
curate test.  Parmentier  (Gaz.  des  Hop., 
p.  136,  '88). 

The  following  recommended  as  a  simple 
method  of  detecting  bile-pigment  in  ic- 
teric fluids :  To  about  1 1/i  fluidrachms 
of  serous  fluid  add  twice  or  thrice  its 
volume  of  concentrated  alcohol,  and 
shake  the  mixture.  Add  as  many  drops 
of  hydrochloric  acid  (10  to  25  per  cent.) 
as  will  be  required  to  dissolve  the  pre- 
cipitation caused  by  the  addition  of  the 
concentrated  spirits,  when  the  fluid  will 
become  clear.  Bring  the  fluid  to  a  boil, 
and  if  gall-pigment  be  present  a  blue- 
green  color  will  appear  within  a  minute 
or  so.  In  a  serous  exudation  containing 
only  1  part  of  bilirubin  to  250,000  parts 
of  fluid,  the  blue-green  color  became  very 
conspicuous.  When  it  is  desired  to  ascer- 
tain the  presence  of  an  insignificant  quan- 
tity of  the  coloring  matter  of  the  bile  in 
concentrated  fluids  rich  in  albumin,  the 
author  proceeds  as  follows:  To  3/i  or  1 
fluidrachm  of  the  fluid  add  four  or  five 
times  its  volume  of  concentrated  spirit, 
which  will  cause  the  precipitation  of  all 
the  proteid  substances  present.  Shake 
well  several  times  and  filter  the  fluid. 
Add  several  drops  of  hydrochloric  acid 
and  boil,  when,  if  gall-pigment  be  pres- 
ent, a  delicate  blue-green  color  will  ap- 
pear. Israel  Hedenius  (Lakaref.  forh., 
vol.  xxix,  Nos.  7,  8,  '95). 

Literature  of  '96-'97-'98. 

Jaundice  may  be  distinguished  from 
the  yellow  hue  caused  by  malaria,  cancer, 
lead  poisoning,  and  some  kidney  affec- 
tions by  placing  a  few  drops  of  the  urine 
in  a  porcelain  dish  and  causing  a  couple 
of  drops  of  nitric  acid  to  flow  against  it. 
If  bile-pigment  be  present,  a  greenish  tint 
will  result,  followed  by  blue,  violet,  and 
a  yellow  or  brown.  John  Inglis  (Colum- 
bus Med.  Jour.;  Monthly  Retrospect, 
Apr.  15,  "98). 

As  no  bile  enters  the  intestine,  the 


JAUNDICE,  OBSTRUCTIVE.  SYMPTOMS. 


246 

fasces  are  pale  or  clay-colored,  on  account 
of  the  large  amount  of  fat  present.  They 
are  pasty  and  usually  foetid.  There  is 
usually  constipation,  but  diarrhoea  is  not 
infrequent,  owing  to  the  decomposition 
in  the  intestines.  There  may  be  no  de- 
rangement of  the  stomach,  but  often 
there  is  loss  of  appetite,  coated  tongue, 
foul  taste,  foetid  breath,  and  epigastric 
fullness  after  food. 

The  clay  color  of  the  stools  is  due  to 
the  undigested  fat,  and  in  jaundiced  pa- 
tients who  are  fed  on  free  fat  food  this 
peculiar  odor  is  not  present.  Strumpell 
(Lehrbuch  d.  spec.  Path,  und  Ther.  d. 
inneren  Krank.,  B.  1,  '88). 

In  the  absence  of  bile  from  the  intes- 
tine, in  jaundice,  there  is  an  increase  in 
undigested  fat  from  6.9  and  10.5  per  cent., 
the  normal  amount,  to  55.2  and  78.5  per 
cent.  Miiller  (Zeit.  f.  klin.  Med.,  B.  12, 
H.  1,  2.  '88). 

Attention  called  to  the  difference  be- 
tween icterus  from  obstruction  and  true 
polycholic  icterus,  in  which  there  is 
hypersecretion  of  bile.  In  the  former  the 
stools  are  alcoholic,  while  in  the  latter 
they  retain  their  normal  color.  Poly- 
cholic icterus,  rare  in  temperate  climates, 
but  very  frequent  in  hot  countries,  is  as- 
sociated with  an  acute  congestion  of  the 
liver,  and  is  accompanied  by  fever.  It 
does  not  last  long  unless  it  occurs  in  re- 
lapses. Icterus,  not  polycholic,  yet  with- 
out discolorization  of  the  stools,  may  also 
occur  when  there  is  incomplete  compres- 
sion of  the  small  bile-ducts.  Jaccoud 
(Jour,  de  Med.  et  de  Chir.  Prat.,  June, 
'90). 

Literature  of  '96-'97-'98. 

Case  of  a  girl  of  10  years,  who  became 
jaundiced  when  six  years  old,  and  re- 
mained so  six  months.  At  thirteen  there 
was  another  attack  of  jaundice  lasting 
eight  months,  and  at  fifteen  one  of  six- 
months'  duration.  The  fourth  attack 
came  on  at  sixteen,  and  when  reported 
had  lasted  four  months.  According  to 
the  mother,  an  inflammation  of  the 
throat  preceded  every  attack.  In  the 
previous  attacks,  especially  the  second, 
there  was  severe  pain  in  the  region  of  the 


stomach  and  liver,  not  colicky.  Chills 
and  fever  have  not  been  present.  Re- 
covery from  the  attacks  begins  suddenly. 
In  the  present  attack  there  is  no  fever, 
the  appetite  is  good,  and  bowels  regular; 
the  patient  is  emaciated  and  feels  weak. 
The  jaundice  is  intense;  there  is  great 
itching.  Ascites  and  enlarged  spleen  are 
absent.  The  liver  is  enlarged  all  over, 
dullness  extending  from  the  upper  border 
of  the  fifth  rib  in  the  mammillary  line  to 
three  fingers'  breadths  below  the  rib. 
The  surface  is  hard,  uneven,  and  sensi- 
tive. The  faeces  for  months  have  been 
without  bile-coloring  matter.  The  case 
is  probably  one  of  gall-stone  with  second- 
ary hypertrophic  cirrhosis  of  the  liver. 
Albu  (Deutsche  med.  YVoch.,  No.  13,  '98). 

Slow  pulse  is  very  characteristic;  it  is 
usually  from  40  to  60,  but  may  be  down 
to  even  20  per  minute.  Such  pulse- 
changes  are  more  frequent  in  catarrhal 
jaundice  and  are  not  usually  of  unfavor- 
able significance.  The  respirations  are 
usually  normal,  but  may  fall  to  10  or  less 
per  minute. 

In  many  protracted  cases  there  is  a 
marked  tendency  to  hemorrhages,  espe- 
cially to  purpura  and  to  subcutaneous  ex- 
travasations. The  blood  requires  in  some 
of  these  cases  eleven  or  twelve  minutes 
to  coagulate  instead  of  three  or  four,  as 
in  normal  states  (Osier). 

Surgical  operations  should  only  be  un- 
dertaken in  case  of  chronic  obstructive 
jaundice  with  due  regard  to  this  change 
in  the  blood. 

Literature  of  '96-'97-'98. 

Icteric  blood  is  deficient  in  sodium  chlo- 
ride. This  depends  on  a  lack  of  XaCl  and 
a  reduction  in  the  volume  of  the  serum. 
The  latter  is  produced  by  an  increase  in 
the  volume  of  the  red  corpuscles,  which, 
in  turn,  is  due  to  the  presence  of  bile- 
salts  in  the  plasma.  V.  Limbeck  (Cen- 
tralb.  f.  innere  Med..  Xo.  33.  '96). 

In  chronic  jaundice  there  is  a  marked 
tendency  to  hemorrhage  and  in  oper- 
ating upon  such  cases  surgeons  have  to 
count  this  as  a  possible  serious  accident. 


JAUNDICE,  OBSTRUCTIVE.    ETIOLOGY  AND  PATHOLOGY.  247 


Within  the  past  few  years,  the  writer  has 
known  of  three  fatal  cases  of  haemor- 
rhage's following  operations  under  these 
conditions.  A  recent  case  suggests  the 
possibility  of  the  value  of  taking  the 
blood-coagulation  time.  The  case  was 
one  of  jaundice  with  pains  suggesting 
gall-stones,  and  Dr.  Finney  operated. 
The  patient  almost  bled  to  death  on  the 
table.  The  wound  was  packed  with 
gauze,  and  the  patient  was  taken  back 
to  the  ward  in  a  very  exhausted  condi- 
tion. He  bled  very  actively  every  time 
an  attempt  was  made  to  remove  the 
gauze,  and  it  was  at  least  three  weeks 
before  all  of  it  was  taken  out  of  the 
wound.  His  blood-coagulation  time,  as 
taken  with  Wright's  tubes,  was  between 
ten  and  eleven  minutes,  more  than  double 
the  normal.  It  certainly  would  be  ad- 
vantageous to  test  this  point  in  cases  of 
chronic  jaundice  before  operation,  and  it 
might  be  worth  while  also  to  follow  out 
Professor  Wright's  suggestion,  and  to 
give  the  calcium  chloride  in  full  doses  for 
a  period  of  ten  days  in  order  to  increase, 
if  possible,  the  coagulability  of  the  blood. 
William  Osier  (Montreal  Med.  Jour., 
Jan.,  '98). 

Pruritus  is  often  a  distressing  symp- 
tom in  the  chronic  forms  of  obstructive 
jaundice.  It  occasionally  precedes  the 
onset  of  the  jaundice.  It  is  worse  at 
night  and  may  be  general  or  localized. 
Scratching  gives  rise  to  various  erup- 
tions. Sweating  is  frequent.  Urticaria, 
lichen,  and  boils  may  be  present,  as  may 
also  xanthelasma. 

Cutaneous  pruritus,  so  common  in 
jaundice  from  retention,  may  appear  and 
persist  for  a  long  time  before  the  icterus 
is  evident.  This  precocious  pruritus  is 
observed  especially  in  cases  in  which  the 
obstruction  to  the  flow  of  the  bile  is 
caused  by  a  neoplasm  situated  some- 
where along  the  course  of  the  biliary  pas- 
sages. Bouchard  (Med.  Rec,  Apr.  14, 
'94). 

Cerebral  symptoms  may  be  marked,  in- 
cluding irritability,  great  despondency, 
and  even  melancholia.  There  are  often 
headache,  vertigo,  and  dullness;  there 


may  be  sleeplessness.  Specially  severe 
symptoms  may  develop  in  persistent 
jaundice  and  quickly  prove  fatal. 
Usually  there  is  slight  fever,  rapid  pulse, 
emaciation,  and  mild  delirium.  From 
this  typhoid  state  the  patient  may  soon 
become  comatose  or  develop  convulsions. 
This  condition  was  formerly  denomi- 
nated cholcemia,  or  sometimes  cholester- 
cemia.  Its  cause  is  uncertain,  but  prob- 
ably most  cases  are  due  to  a  "terminal 
infection." 

Literature  of  '96-'97-'98. 

Cholsemia  may  be  diagnosticated  by 
the  blood-plasma  separated  in  the  centrif- 
ugal tube,  before  the  appearance  of  the 
icteric  hue  of  the  skin.  G.  W.  McCaskey 
(N.  Y.  Med.  Jour.,  Apr.,  '97). 

Etiology. — This  class  includes  the 
cases  that  "result  from  obvious  mechan- 
ical obstruction"  and  are  "independent 
of  changes  in  the  blood  or  bile"  (Hun- 
ter). 

Murchison  classified  this  group  as  fol- 
lows:— 

1.  Obstruction  by  foreign  bodies 
within  the  duct,  as  gall-stones,  inspis- 
sated bile,  parasites,  etc. 

Literature  of  '96-'97-'98. 

Catarrhal  jaundice  is  not  merely  a  me- 
chanical plugging  of  the  bile-ducts  with 
mucus,  or  a  closure  of  the  ducts  with  in- 
flammatory swelling,  but  is  really  toxic 
in  character,  ordinary  catarrhal  jaundice 
being  due  to  toxic  substances  developed 
in  the  alimentary  canal.  Obstructive 
jaundice  is  due  to  gall-stones,  tumors, 
hepatic  abscesses,  and  cirrhosis.  If  jaun- 
dice is  associated  with  gall-stones,  it  is 
generally  due  to  inflammation  rather 
than  to  obstruction.  Ren  vers  (Modern 
Med.  and  Bact.  Review,  Apr.,  '97). 

2.  Obstruction  by  inflammatory  tume- 
faction of  the  duodenum,  or  of  the  lining 
membrane  of  the  duct  and  exudation 
into  its  interior. 


248 


JAUNDICE,  OBSTRUCTIVE.    ETIOLOGY  AND  PATHOLOGY. 


Catarrhal  or  simple  jaundice  results 
from  the  following  causes:  1.  Duodenal 
catarrh,  in  whatever  way  produced,  most 
commonly  following  an  attack  of  indi- 
gestion. It  is  most  frequently  met  with 
in  young  persons,  but  may  occur  at  any 
age,  and  may  follow  not  only  errors  in 
diet,  but  also  cold,  exposure,  and  malaria, 
as  well  as  the  conditions  associated  with 
portal  obstruction,  chronic  heart  disease, 
and  Bright's  disease.  2.  Emotional  dis- 
turbances may  be  followed  by  jaundice, 
which  is  believed  to  be  due  to  catarrhal 
swelling.  Cases  of  this  kind  are  rare  and 
the  anatomical  condition  is  unknown. 
3.  Simple  or  catarrhal  jaundice  may  oc- 
cur in  epidemic  form.  4.  Catarrhal  jaun- 
dice is  occasionally  seen  in  the  infectious 
fevers,  such  as  pneumonia  and  typhoid 
fever.  William  Osier  ("Principles  and 
Pract.  of  Med.,"  p.  430). 

3.  Obstruction  by  stricture  or  obliter- 
ation of  the  duct,  as  may  result  from 
perihepatitis,  or  from  a  cicatrix  in  the 
duct  or  at  its  mouth  in  the  duodenum. 

Case  of  chronic  obstructive  jaundice 
due  to  a  narrowing  of  the  ductus  com- 
munis choledochus  by  a  cicatricial  band 
situated  just  at  the  junction  of  the  cystic 
and  hepatic  ducts.  The  gall-bladder  was 
atrophied.  The  liver  and  spleen  con- 
tained pure  cultures  of  the  bacillus  coli 
communis.  Benzaoon  (Bull,  de  la  So- 
ciete  Anat.,  No.  6,  '93). 

The  occurrence  of  jaundice  is,  as  a  rule, 
only  possible  when  there  is  an  obstruc- 
tion of  the  common  bile-duct.  There  are 
one  or  two  exceptions,  viz.:  a  rare  form 
of  blood-dyscrasia  and  yellow  fever. 
Biliousness  is  the  result  of  functional  de- 
rangement of  the  liver,  while  jaundice  is 
the  result  of  obstruction  of  the  common 
duct.  Jacob  Michaux  (Gaillard's  Med. 
Jour.,  vol.  Ixvii,  No.  1). 

Literature  of  '96-'97-'98. 

Case  of  fatal  infantile  jaundice  from 
congenital  narrowing  of  the  bile-duct. 
J.  A.  C.  Kynoch  (Edinburgh  Med.  Jour., 
July,  '96)/ 

4.  Obstruction  by  tumors'  closing  the 
orifice  of  the  duct  or  growing  into  its 
interior. 


Causes  of  icterus  gravis:  1.  Mechan- 
ical occlusion  of  the  lumen  of  the  cystic 
and  common  duets  by  calculi,  hepatic 
growths,  enlarged  head  of  the  pancreas, 
carcinoma  of  the  duodenum,  tumors  of 
the  transverse  colon,  etc.  2.  Acute  yel- 
low atrophy.  3.  Terminal  stage  of  atro- 
phic cirrhosis.  Mester  (Deutsche  med. 
Woch.,  Nov.  27,  '90). 

Literature  of  '96-'97-'98. 

Four  cases  in  which  death  followed 
symptoms  of  obstructive  jaundice  due  to 
cancer  of  the  ductus  choledochus  com- 
munis with  signs  of  excessive  amount  of 
colloid  material  in  the  thyroid  gland.  In 
those  cases,  the  antitoxic  function  of  the 
liver  having  been  notably  impaired,  the 
thyroid  was  excited  to  vicarious  action 
by  the  toxic  substances  circulating  in  the 
blood.  Lindemann  (Archiv  fiir  pathol. 
Anat.,  etc.;  Gaz.  Hebdom.  de  Med.  et  de 
Chir.,  Nov.  28,  '97). 

Examination  of  the  liver  from  a 
woman,  aged  53,  who  had  died  after 
symptoms  of  obstructive  jaundice.  There 
Avas  a  large  caseating  gland  surrounded 
by  a  dense  mass  of  fibrous  tissue  involv- 
ing the  hepatic  duct.  There  was  also 
some  perihepatitis  with  several  small 
abscesses  throughout  the  liver.  Whyte 
(Brit.  Med.  Jour.,  Jan.  1,  '98). 

5.  Obstruction  by  pressure  on  the  duct 
from  without  by  (a)  enlarged  glands,  (b) 
hepatic  tumor,  (c)  tumor  of  the  pylorus, 
(d)  tumor  of  the  pancreas,  (e)  tumor  of 
the  kidney,  (/)  omental  tumor,  (g)  an 
abdominal  aneurism,  (h)  faecal  accumula- 
tion in  the  colon,  (i)  ovarian  or  uterine 
tumors. 

Tight  lacing  has  a  decided  effect  on 
lessening  the  flow  of  bile.  The  free  and 
unfettered  action  of  the  diaphragm  is 
essential  to  normal  biliary  secretion  and 
affects  evacuation  of  the  bile-ducts  much 
in  the  same  way  as  succussion  of  the 
liver  which  saddle  exercise  affords. 
W.  G.  Collins  (Lancet,  Mar.  17.  '88). 

Conclusions  based  on  a  study  of  jaun- 
dice and  its  treatment:  1.  Long-con- 
tinued biliary  stasis,  compromising  the 
secreting  cells  of  the  parenchyma  of  the 
liver  and  producing  a  certain  anemia  of 


JAUNDICE,  OBSTRUCTIVE.  TREATMENT. 


249 


the  organ,  markedly  reduces  and  some- 
times suppresses  the  secretion  of  the 
biliary  acids.  The  gravity  of  the  phe- 
nomena described  under  the  name  of 
biliary  intoxication  does  not,  therefore, 
depend  upon  the  action  of  these  acids. 

2.  The  scarcity  or  absence  of  bile  in  the 
intestinal  canal  modifies  very  seriously 
the  chemical  processes  there  taking  place. 

3.  One  of  the  most  common  of  the  gastric 
changes  in  the  icterus  is  the  suppression 
of  hydrochloric-acid  secretion.  4.  There 
is  little  or  no  loss  of  carbonate  of  sodium 
in  these  cases.  5.  The  reaction  of  the 
contents  of  the  stomach  is  usually  alka- 
line, less  often  neutral  or  faintly  acid. 
6.  The  physiological  activity  of  the  bile 
and  of  the  pancreatic  juice  in  the  in- 
testine is  retarded.  7.  The  chlorides  in 
the  urine  is  increased;  there  is  a  dimi- 
nution of  urea,  with  an  abundance  of 
products  of  the  aromatic  series.  8.  The 
more  marked  these  characters,  the  graver 
the  disease  and  its  clinical  manifesta- 
tions. 9.  Alkaline  treatment  does  not 
modify  these  conditions.  The  effect  of 
the  acid  treatment  is,  however,  to  dimin- 
ish the  chlorides,  to  restore  the  normal 
acidity  of  the  urinary  reaction,  to  in- 
crease the  excretion  of  urea,  and  to  re- 
duce that  of  the  aromatic  products;  and, 
at  the  same  time,  there  is  a  progressive 
increase  in  the  weight  of  the  body. 
Alivia  (Med.  Rec,  Apr.  14,  '94). 

Treatment. — The  prognosis  and  treat- 
ment are  further  considered  in  dealing 
with  the  various  diseases  that  give  rise 
to  obstructive  jaundice.  (See  Liver, 
Diseases  of.) 

The  following  substances  have  been 
found  by  experiment  to  increase  the  flow 
of  bile:  Group  1.  Urea,  oil  of  turpentine, 
and  terpine.  Chlorate  of  potassium  in- 
creased the  flow  by  once  or  twice  the 
normal.  Further,  benzoate  and  salicylate 
of  sodium,  salol,  euonymin,  and  muscarin 
used  subcutaneously  increase  the  secre- 
tion two  or  three  times  the  normal 
amount.  Group  2.  Substances  producing 
only  a  slight  or  doubtful  and  inconstant 
increase  are:  alkaline  salts,  Carlsbad 
salts,  propylamin,  antipyrine,  aloes,  can- 
tharitic  acid  and  rhubarb,  hydrastis  Can- 
adensis, ipecac,  and  boldo.   Thus,  cathar- 


tics and  the  alkaline  salts  are  not  chola- 
gogic  in  non-cathartic  doses.  Group  3. 
Substances  diminishing  the  secretion: 
iodide  of  potassium,  calomel,  iron  and 
copper,  atropine,  and  strychnine.  In  re- 
gard to  calomel,  the  writers  have  not 
been  able  to  confirm  Rutherford,  who  be- 
lieved that  what  cholagogic  action  calo- 
mel had  was  due  to  the  transformation 
into  corrosive  sublimate.  The  last-named 
substance  given  by  itself  produced  no  in- 
crease. Prevost  and  Binet  (Revue  Med. 
de  la  Suisse  Rom.,  May  to  July,  '88). 

From  a  uniform  success  of  6  cases  the 
subcutaneous  injection  of  hydrochlorate 
of  pilocarpine  is  recommended  for  the  re- 
lief of  itching  in  patients  with  jaundice. 
Goodhart  (Brit.  Med.  Jour.,  Jan.  19,  '89). 

Thirteen  cases  of  catarrhal  jaundice  in 
children  treated  without  drugs,  by  the 
use  of  the  faradic  current,  daily  applica- 
tions of  five  minutes  being  usually  made. 
One  electrode  was  placed  over  the  gall- 
bladder and  the  other  over  the  spine  at 
the  same  level,  or  the  two  electrodes  were 
grasped  with  one  hand  and  applied  in  the 
region  of  the  gall-bladder,  and  a  current 
used  which  was  powerful  enough  to  ex- 
cite strong  contractions  in  the  abdominal 
muscles.  A  milk  diet  was  usually 
ordered. 

The  results  showed  striking  improve- 
ment. 

Three  cases  were  treated  by  the  cur- 
rent alone,  an  ordinary  mixed  diet  being 
allowed.  In  these  cases,  as  well,  marked 
improvement  followed  after  the  second 
seance.  The  average  number  of  applica  - 
tions  required  before  recovery  was  seven 
or  eight.  Kraus  (Archiv  f.  Kinderh., 
B.  10,  p.  231,  '89). 

Successful  treatment  of  catarrhal  jaun- 
dice consists  simply  in  the  rectal  injec- 
tion daily  of  1  to  2  pints  of  cold  water 
at  first  of  a  temperature  of  57°  F., 
then  of  59°  to  65°  F.  The  fasces  became 
colored  in  the  second  to  the  fourth  day 
and  general  symptoms  rapidly  improved. 
Krull  (Berliner  klin.  Woch.,  p.  159,  '87). 

The  good  effects  of  olive-oil  in  the 
treatment  of  jaundice  due  to  simple  ob- 
struction emphasized.  T.  Oliver  (Lancet, 
Oct.  7,  '93). 

Massage  recommended  in  the  treatment 
of  catarrhal  jaundice.    The  method  con- 


250 


JAUNDICE,  TOXEMIA.    ETIOLOGY  AND  PATHOLOGY. 


sists  in  rhythmical  compression  of  the 
hepatic  region  for  ten  minutes,  thrice 
daily.    Wechsler  (Wratsch,  No.  19,  '93). 

Literature  of  '96-'97-'98. 

For  itching  in  jaundice  the  following 
is  recommended  to  be  rubbed  in  several 
times  a  day:  — 

I£  Ichthyol,  1  V4  to  2  Va  drachms. 
Alcohol, 

Ether,  of  each,  2  fluidounces. 
Boullard  (Ges.  Therapie,  p.  380,  '98). 

II.  Toxsemic  Jaundice  (Haematoge- 
nous  Jaundice;  Haemo-hepatogenous 
Jaundice;  Jaundice  of  Polychromia ; 
Non-obstructive  Jaundice). 

In  this  form  there  is  said  to  be  no 
obstruction  in  the  bile-passages.  Such 
in  most,  if  not  all,  cases  is  not  correct, 
because,  although  the  larger  ducts  are 
free,  the  bile-radicles  within  and  around 
the  hepatic  lobules  are  obstructed  to  a 
greater  or  less  extent  by  swelled  epithe- 
lium, pigment-granules,  and  crystals  of 
leucin  and  tyrosin.  The  obstruction  in 
these  cases  is  shifted  from  the  larger 
ducts  to  the  biliary  radicles,  many  of 
which  escape,  so  that  the  obstruction  is 
rarely  complete.  The  cause  acts  on  the 
liver-substance  in  general  and  must, 
therefore,  be  toxic  and  conveyed  to  it  by 
the  blood,  either  of  the  general  or  the 
portal  circulation.  The  toxin  acts  on  the 
blood,  and  in  its  excretion  by  the  liver 
leads  to  the  secretion  of  a  viscid  bile,  to 
irritation  of  the  biliary  radicles,  and  it 
may  be  to  degenerative  changes  in  the 
liver-cells. 

There  are  cases  of  obstructive  jaundice 
in  which  the  occlusion  occurs  within  the 
biliary  lobules  and  is  due  to  swelling  of 
the  epithelial  cells.  The  swelling  and  de- 
generation of  the  hepatic  cells  are  the  re- 
sult of  the  action  of  toxic  substances 
introduced  through  the  circulation.  The 
treatment  of  this  form  of  jaundice  con- 
sists in  the  regulation  of  the  diet,  the 
improvement  of  the  circulation  and  the 
blood,  and  remedies  addressed  to  the  liver 


to  stimulate  more  active  secretion,  but, 
first  of  all,  to  reduce  the  cellular  swelling 
so  as  to  free  the  terminal  biliary  capil- 
laries. Porter  (Amer.  Med.-Surg.  Bull., 
Dec.  1,  '94). 

Hunter  makes  three  groups  of  this 
class  of  cases: — 

1.  Jaundice  due  to  poisons,  as  toluy- 
leudiamin,  phosphorus,  arseniuretted 
hydrogen,  and  snake-venom. 

2.  Jaundice  occurring  in  various  spe- 
cific fevers,  as  yellow  fever,  malaria, 
pyaemia,  enteric  fever,  typhus,  and  scar- 
latina. 

3.  Jaundice  occurring  in  obscure  in- 
fective conditions,  as  in  epidemic,  infec- 
tious, febrile,  or  malignant  jaundice, 
icterus  gravis,  Weil's  disease,  and  acute 
yellow  atrophy  of  the  liver. 

In  this  class  the  jaundice  is  usually 
less  intense  than  in  obstructive  jaundice. 
There  is  only  a  partial  absorption  of  the 
bile-pigment  by  the  lymphatics  of  the 
liver.  Bile  appears  in  the  stools  at  some 
period  of  the  history;  it  may  be  in  excess, 
causing  very  dark  faecal  discharges. 
There  is  usually  more  constitutional  dis- 
turbance than  in  obstructive  jaundice. 
In  severe  cases  this  is  very  pronounced — 
high  fever,  dry  tongue,  delirium,  subsul- 
tus,  convulsions,  haemorrhages  from  vari- 
ous parts,  black  vomit,  all  indicating 
severe  constitutional  infection. 

All  cases  usually  show  (1)  destructive 
changes  in  the  blood;  (2)  alterations  in 
the  quantity  and  quality  of  the  bile;  (3) 
changes  in  the  liver-cells  and  bile-ducts, 
varying  in  degree  according  to  the  irri- 
tant power  of  the  toxin. 

The  destructive  changes  in  the  blood 
are  shown  by  the  occurrence  of  haemor- 
rhages especially  from  the  mucous  sur- 
faces, as  of  the  nose  and  stomach.  The 
black  vomit  of  yellow  fever  furnishes  a 
striking  example  of  such  haemorrhages. 
The  changes  in  the  bile  are  characterized 
by  its  increased  viscidity,  great  increase 


The  British  Medical  Journal  Reviews  The  Year=Book 
of  Treatment  for  1899. 

(Issue  of  March  4,  1899.) 

.  REVIEWS. 


The  Yearbook  of  Treatment  for  1899.  A  Critical  Review 
for  Practitioners  of  Medicine  and  Surgery.  Cassell  and  Com- 
pany, Limited,  London,  Paris,  Melbourne.  (Crown  Octavo, 
pp.  576,  $2.00  net. ) 

The  Yearbook  of  Treatment  is  now  so  well  established  in  the  favour 
of  the  profession,  not  only  in  this  country  but  in  Greater  Britain 
and  in  the  United  States,  that  it  is  hardly  necessary  to  do  more 
than  announce  the  appearance  of  the  fifteenth  issue.  The  book  gives 
a  bird's  eye  view  of  the  whole  field  of  therapeutics,  and  it  is  inter- 
esting to  note  the  points  in  the  mental  landscape  thus  presented 
that  stand  out  most  prominent  at  the  first  glance.  This  year  tuber- 
culosis overtops  everything  else.  The  most  valuable  feature  in  the 
new  issue  of  the  Yearbook,  and  a  novel  one,  is  an  article  on  the 
Open-air  Treatment  of  Phthisis  by  Dr.  F.  W.  Burton-Fanning, 
which  is  one  of  the  best  and  briefest  accounts  of  the  subject  that 
we  have  met  with.  Dr.  Vincent  D.  Harris  deals  with  Diseases  of 
the  Lungs  and  Organs  of  Respiration,  and  here  also  the  prevention 
of  tuberculosis  and  its  treatment  in  sanatoria  hold  the  place  of 
honour.  In  regard  to  diseases  of  the  heart  and  circulation,  Drs.  G. 
A.  Gibson  and  James  A.  Dunlop  have  but  little  in  the  way  of 
progress  to  chronicle,  and  the  same  thing  may  be  said  concerning 
most  of  the  other  articles,  which  are  contributed  by  writers  whose 
names  are  a  guarantee  of  their  competence  for  the  task.  Needless 
to  say  they  have  done  their  work  thoroughly  well,  as  far  as  there 
was  material  available  for  the  purpose;  but  even  the  most  practised 
of  u  eminent  hands  "  cannot  make  bricks  without  straw.  Speaking 
of  dermatology,  Mr.  Malcolm  Morris  says  that  "  the  tide  of  progress 
flows  more  strongly  at  one  time  than  another,  and  this  year  has 
been  a  period  of  slack  water;"  and  this  remark  may  be  extended  to 
therapeutics  in  general  during  the  last  twelve  months. 

The  Yearbook  of  Treatment  is  so  conveniently  arranged  and  so 
fully  indexed,  contains  so  much  matter,  and  is  withal  of  such  man- 
ageable size  that  it  is  no  wonder  it  should  have  become  indispen- 
sable to  all  members  of  the  medical  profession  who  wish,  with  the 
least  possible  trouble,  to  keep  themselves  abreast  of  therapeutic 
progress.  In  its  adaptation  to  its  purpose  it  reminds  us  of  a  royal 
personage's  description  of  an  ideal  secretary,  who  was  "  never  out  of 
the  way  and  never  in  the  way."  So  in  the  Yearbook  of  Treatment 
the  busy  practitioner  will  find  at  once  just  what  he  wants,  and  no 
more.  He  is  not  irritated  by  foolish  or  crude  fancies  which  might 
lead  him  to  say  in  his  haste  that  all  men  are  liars.  The  gaseous 
elements  in  the  therapeutic  output  of  the  year  have  been  evapo- 
rated, till  only  a  solid  residue  of  useful  knowledge  is  left.  We  are 
gratified  to  observe  that,  as  in  former  issues,  the  Epitome  of  the 
British  Medical  Journal  has  proved  of  service  to  the  writers 
of  many  of  the  articles,  though  the  indebtedness  is  not  always 
acknowledged. 

We  commend  this  edition  of  the  Yearbook  to  the  profession,  as 
giving  in  the  smallest  compass  the  greatest  amount  of  information 
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250 


sists 

hepal 

daily 


Foi 
is  rec 
times 


Bor 

II.  To 

nous  Jau: 
Jaundic 
Non-obstr 

In  this 
obstructio 
in  most,  i 
because,  a 
free,  the  b 
the  hepati 
greater  or 
Hum,  pigr 
leucin  and 
these  case 
ducts  to  1 
which  esca 
rarely  com 
liver-substi 
therefore,  1 
the  blood, 
portal  circi 
blood,  and 
leads  to  th 
irritation  c 
may  be  to 
liver-cells. 

There 
in  whic 
biliary 
the  epit 
genera  li 
suit  of 
introdiK 
treatme: 
sists  in 
improve 
blood,  ai 


JAUNDICE,  TOXEMIA.    ETIOLOGY  AND  PATHOLOGY. 


251 


in  its  pigment,  and  lessening  of  the  bile- 
acids.  The  parenchymatous  changes  in 
the  liver  are  evidence  of  the  action  of  the 
toxins  on  the  liver.  Similar  changes 
occur  in  the  kidneys. 

In  many  varieties  the  toxins  that  excite 
these  changes  are  generated  in  the  in- 
testinal tract,  as  gastro-intestinal  symp- 
toms are  usually  prominent  in  the  initial 
stage  of  the  illness.  In  this  way  we  may 
account  for  the  absence  of  specific  organ- 
isms in  the  liver  in  acute  yellow  atrophy, 
for  example. 

In  many  cases  of  jaundice  the  sequel 
of  events  is  first  an  accumulation  of  irri- 
tant products  in  the  liver,  causing  an 
irritation  and  inflammation  of  the  he- 
patic ducts,  with  intestinal  inflammation 
following  it.  Chauffard  (Revue  Gen.  de 
Clin,  et  de  Ther.,  p.  678,  '88). 

Case  of  a  strong,  well-nourished  boy, 
who,  five  weeks  after  birth,  was  observed 
to  be  jaundiced  over  the  upper  half  of  the 
body.  The  discoloration  descended  to  the 
umbilicus,  where  it  ended  abruptly,  being 
sharply  defined  by  a  well-marked  line 
encircling  the  body.  By  the  fourth  week 
of  treatment  recovery  was  complete,  and 
during  this  time  there  was  no  disturb- 
ance of  the  general  health.  McHardy 
(Brit.  Med.  Jour.,  Oct.  31,  '91). 

The  bacillus  coli  detected  in  the  blood 
and  organs  of  a  patient  who  died  of  ic- 
terus gravis.  He  does  not  think,  how- 
ever, that  this  micro-organism  may  be  re- 
garded as  the  sole  producer  of  this  form; 
he  is  rather  inclined  to  believe  that  the 
infectious  hepatic  process  may  be  pro- 
duced by  germs  of  a  different  kind.  Vin- 
cent (Archives  Gen.  de  Med.,  Dec.  1,  '93). 

The  form  of  icterus  gravis  in  which  the 
bacillus  coli  is  found  is  accompanied  by 
lowering  of  the  temperature,  while  the 
other  forms  of  the  same  disease  which  are 
accompanied  by  fever  are  characterized 
by  the  presence  in  the  liver  and  blood  of 
pyogenic  microbes.  Undoubtedly,  how- 
ever, the  micro-organisms  play  a  role  in 
the  production  of  the  lesions  and  symp- 
toms of  icterus  gravis.  Hanot  (Le  Bull. 
MeU,  Feb.  21,  May  6,  '94). 

Case  of  primary  icterus  gravis  observed 
in  which  the  temperature  always  ranged 


below  the  normal.  Death  followed.  Cul- 
tivations made  with  the  blood  and  liver 
remained  sterile  and  no  micro-organism 
was  demonstrated  on  staining  the  sec- 
tions of  that  organ.  J.  Durante  (Bull,  de 
la  Soc.  Anat.,  No.  24,  '94). 

Four  cases  of  icterus  gravis  in  which 
the  results  of  bacteriological  examination 
led  the  writer  to  conclude  that  they 
could  be  regarded  as  variable  stages  of 
the  same  form  of  septicaemia  caused  by 
streptococci.  Babes  (Revue  des  Sci.  Med. 
en  France  et  a,  l'Etranger,  July  15,  '94). 

Three  cases  of  icterus  occurring  in 
syphilitic  subjects.  The  cases  were  re- 
markable in  that  the  icterus  occurred 
either  at  the  time  of  the  first  skin  erup- 
tion or  at  the  time  of  the  recurrences. 
The  symptoms  were  essentially  those  of 
the  ordinary  icterus  catarrhalis.  The 
liver  was  also  appreciably  enlarged.  Un- 
like the  ordinary  icterus,  this  was  made 
to  disappear  very  rapidly.  Ordinary 
methods  produced  but  slight  effect  upon 
it,  but  mercury  caused  a  rapid  disappear- 
ance. Joseph  (Arch.  f.  Derm.  u.  Syph., 
B.  39,  H.  3). 

Icterus  may  be  directly  ascribed  to 
syphilis  in  many  cases  where  there  is  (1) 
absence  of  the  ordinary  causes  of  jaun- 
dice; (2)  where  there  is  coincidence  of 
symptoms  of  the  two  affections  in  very 
pronounced  form;  (3)  where  the  course 
of  manifestations  of  both  diseases  runs 
parallel. 

The  abuse  of  alcohol  in  such  cases  is 
undoubtedly  nothing  more  than  a  pre- 
disposing cause  Chapotot  (Lyon  Med., 
Nov.  22,  '92). 

Three  cases  of  icterus  coming  on  at  an 
early  period  of  syphilis  noted.  Table  of 
forty-six  additional  cases  added  with  a 
view  of  establishing  the  differential  diag- 
nosis between  simple  catarrhal  and  syphi- 
litic icterus.  The  latter  usually  comes 
on  suddenly,  without  being  preceded  by 
the  digestive  disturbances  which  are  the 
prelude  of  the  catarrhal  form;  in  some 
cases  the  digestion  remains  excellent 
throughout,  though,  as  in  catarrhal  jaun- 
dice, there  is  a  distaste  for  fats.  An- 
other point  to  be  noted  is  the  absence  of 
any  etiological  factor  except  syphilis. 
The  jaundice  usually  appears  with  the 
first  eruption,  and  is  most  frequent  in 


252 


JAUNDICE,  TOXAEMIA.    ETIOLOGY  AND  PATHOLOGY. 


females.  O.  Lasch  (Berliner  klin.  Woch., 
Oct.  1,  '94). 

Fatal  case  of  icterus  observed  in  the 
secondary  stage  of  syphilis,  the  entire 
liver  being  found  at  necropsy  to  be  in- 
vaded by  gummatous  hepatitis.  Roque 
and  Devic  (Le  Bull.  Med.,  Nov.  11,  '94). 

Jaundice  may  occur  as  a  consequence 
of  the  administration  of  filix  mas,  par- 
ticularly in  combination  with  an  oil,  as 
castor-oil.  In  these  cases  there  was  great 
destruction  of  red  corpuscles,  and  this  is, 
therefore,  looked  upon  as  the  cause. 
Grawitz  (Berlin,  klin.  Woch.,  p.  1171, 
'94). 

Literature  of  '96-'97-'98. 

The  icterus  of  pneumonia  is  due  to  an 
accidental  hemolytic  action  of  the  dip- 
lococcus,  and  is,  therefore,  haemogenic. 
Banti  (Centralb.  f.  Bakt.  u.  Inf.,  Dec.  10, 
'96). 

The  mechanical  theory  of  jaundice  ap- 
pears inadmissible.  In  so-called  catar- 
rhal jaundice  there  is,  in  reality,  no 
catarrh  of  the  ductus  choledochus. 

From  an  anatomical  point  of  view,  the 
mucous  plug,  which  has  been  found  in 
the  common  bile-duct  in  cases  of  catar- 
rhal jaundice,  is  met  with  also  in  subjects 
who  have  never  presented  any  yellow 
tint  of  the  skin.  The  alleged  imperme- 
ability of  the  ductus  choledochus  in  jaun- 
dice does  not  exist.  The  principal  argu- 
ment against  the  mechanical  theory  is 
the  rapidity  with  which  jaundice  super- 
venes after  an  attack  of  hepatic  colic 
(usually  about  three  hours). 

Icterus,  like  the  bile,  can  only  origi- 
nate in  the  liver,  and  there  is  conse- 
quently no  hematogenous  jaundice, 
properly  so  called.  Jaundice  supervenes 
when  a  portion  of  the  bile  passes  into  the 
lymphatic  spaces,  and  thence  into  the 
thoracic  duct  and  the  blood.  The  condi- 
t ion  must,  therefore,  be  attributed  to  a 
disturbance  of  the  secretory  function  of 
the  hepatic  cells.  It  is,  in  fact,  a  para- 
cholia. 

Jaundice  by  autointoxic;i1  ion  is  the  re- 
sult of  a  peculiar  arrangement  of  the  he- 
patic cells,  and  the  same  remark  may  pos- 
sibly hold  good  of  icterus  neonatorum. 
Catarrhal  jaundice  is  an  infective  para- 
cholia,  as  are  also  the  jaundice  observed 


in  Weil's  disease  and  that  of  acute  yellow 
atrophy  of  the  liver.  Idiopathic  jaun- 
dice should  be  treated  as  an  infective 
disease.  Pick  (Sem.  Med.;  Amer.  Med.- 
Surg.  Bull.,  Jan.  10,  '97). 

Observations  based  on  57  cases  of  jaun- 
dice occurring  among  15,799  cases  of 
early  syphilis.  Syphilitic  jaundice  is 
characterized  by  (1)  its  appearance  in 
the  early  secondary  stage,  (2)  the  pres- 
ence of  fresh  specific  manifestations,  (3) 
the  influence  of  treatment,  and  (4)  its 
sudden  development  without  gastric  dis- 
turbance. Long  duration  is  not  char- 
acteristic of  syphilitic  jaundice.  In  typ- 
ical cases  this  icterus  occurs  at  a  time 
when  syphilis  affects  the  skin  and  mu- 
cous membranes.  Hepatic  enlargement 
is  not  a  striking  feature  in  the  disease. 
In  22  out  of  50  cases  the  jaundice  was 
noted  within  six  months  after  the  infec- 
tion. The  syphilis  in  most  of  the  cases 
was  severe.  In  50  cases  cutaneous  affec- 
tions were  present  in  18,  affections  of  the 
mucous  membranes  in  16.  Marked  gland- 
ular enlargement  was  present  in  41  out 
of  50  cases.  Werner  (Munch,  med. 
Woch.,  July  6,  '97). 


Literature  of  'dG-W-'dS. 

Accounts  of  five  patients  presenting 
more  or  less  analogous  symptoms.  They 
all  have  chronic  jaundice  of  moderate  de- 
gree, with  occasional  periods  of  exacerba- 
tion. In  the  intervals  between  the  crises 
the  liver  is  not  at  all  or  only  slightly 
enlarged,  but  the  spleen  is  always  large, 
and  seems  abnormally  hard  to  the  touch. 
During  the  crises  the  jaundice  deepens 
and  the  spleen  becomes  still  more  en- 
larged and  tender  to  pressure,  while  the 
liver  undergoes  only  a  moderate  uniform 
increase  in  size,  remaining  smooth  and 
soft.  The  fa?ces  are  always  colored,  ex- 
cepting occasionally  during  the  crises, 
when  their  color  may  be  temporarily 
more  or  less  completely  lost.  During  the 
crises  the  urine  becomes  icteric  and  gives 
distinctly  Gmelin's  reaction,  though 
usually  during  a  short  period  only.  At 
other  times  the  urine  contains  urobilin 
and  occasionally  modified  bile-pigments, 
but  Gmelin's  reaction  can  never  be  ob- 
tained, though  this  reaction  can  always 
be  produced  in  the  serum  of  the  patient's 


JAUNDICE.    ICTERUS  NEONATORUM.  SYMPTOMS. 


253 


blood.  There  appears  to  be  no  special 
tendency  to  obstruction  in  the  portal  cir- 
culation, to  enlargement  of  the  subcu- 
taneous abdominal  veins,  ascites,  tym- 
panites, or  haemorrhoids.  In  all  the  pa- 
tients there  were  old  troubles  in  connec- 
tion with  the  functions  of  the  digestive 
tract.  All  five  patients  were  decidedly 
anaemic.  There  may  have  been  slight 
fever  during  some  of  the  crises,  but  other- 
wise the  icterus  is  unaccompanied  by  any 
abnormal  rise  of  temperature.  The  peri- 
ods of  exacerbation  appear  sometimes  to 
terminate  with  a  fit  of  polyuria.  Some 
of  the  crises  suggested  the  possibility  of 
cholelithiasis,  but  gall-stones  could  not 
be  found  in  the  faeces. 

Affection  might  be  termed  "chronic  in- 
fectious icterus  with  splenic  enlargement 
and  crises  of  exacerbation.'* 

Treatment  recommended  consists  in 
careful  general  hygiene,  strict  antidys- 
peptic  regimen,  milk  diet  during  the  ex- 
acerbations, sustaining  the  strength,  and 
seeing  that  the  excretory  functions  are 
properly  performed.  G.  Hayem  (Presse 
Med.,  Mar.  9,  '98). 

Jaundice  is  a  somewhat  rare  complica- 
tion of  pregnancy,  Karl  Braun  having 
observed  the  grave  form  only  once  in 
28,000  pregnant  women,  and  Winckel 
only  once  in  16,000  cases.  William  B. 
Young  (Med.  News,  Nov.  12,  '98). 

Icterus  observed  in  four  cases  from 
the  use  of  lactophenin.  Kurt  Witthauer 
(Ther.  Monats.,  H.  2,  S.  111.  98). 

In  some  cases,  as  in  pyaemia  and  snake- 
venom,  the  poison  finds  its  way  to  the 
liver  through  the  general  circulation. 

Icterus  Neonatorum. 

Definition. — Icterus  neonatorum  is  a 
mild  transitory  form  of  jaundice  of  un- 
certain causation  appearing  in  infants 
soon  after  birth.  There  is  also  a  severe 
form  of  jaundice  caused  by  congenital 
absence  or  occlusion  of  the  hepatic  duct, 
or  due  to  septic  infections,  especially 
pylephlebitis.  As  this  form  does  not 
arise  from  the  same  condition  in  the 
adult,  it  is  wiser  to  confine  the  true 
"icterus  neonatorum"  to  the  first  form. 

Symptoms. — The  icteric  tinge  is  gener- 


ally the  only  symptom,  the  child  other- 
wise being  well.  It  occurs  in  delicate 
children  oftener  than  in  the  strong.  It 
is  seen  more  frequently  in  hospitals  than 
in  private  practice,  perhaps  because  the 
light  is  better  in  the  hospitals  and  records 
are  more  carefully  made.  It  is  of  fre- 
quent occurrence,  being  noted  in  as  many 
as  80  or  even  90  per  cent,  in  some  reports. 
It  is  probable  that  careful  examination 
of  all  infants  will  reveal  this  large  ratio. 
When  very  slight  it  may  be  best  detected 
on  the  red  skin  rendered  pallid  by  press- 
ure. It  usually  appears  on  the  second  or 
third  day,  increases  for  a  day  or  two  and 
then  disappears,  the  whole  duration  be- 
ing from  four  to  five  days  to  a  week,  last- 
ing a  fortnight  in  severe  cases  only. 

"It  is  first  and  most  distinctly  seen  on 
the  face — especially  on  the  forehead  and 
about  the  mouth — and  in  the  chest;  later 
it  appears  on  the  sclerotics,  and  last  of  all 
on  the  hands  and  feet"  (Thomson). 

In  contrast  with  ordinary  obstructive 
jaundice  the  sclerotics  are  discolored  only 
slightly  and  late. 

The  urine  is  usually  normal,  not  stain- 
ing the  napkin;  but  in  severe  cases  bile- 
pigment  is  present  in  it. 

Dyspepsia,  nausea,  vomiting,  eructa- 
tions, and  flatulence,  with  sour  and  green 
stools,  are  constant  symptoms  of  icterus 
neonatorum,  and  occur  either  simultane- 
ously or  soon  after  the  appearance  of  the 
jaundice.  In  many  cases  fever  is  present, 
especially  in  the  evening.  The  cause  con- 
sists in  a  gastro-intestinal  catarrh  caused 
by  the  irritation  produced  by  the  first 
food,  which  is  often  of  an  unsuitable 
character.  The  catarrh  extends  to  the 
common  bile-duct,  which  becomes  ob- 
structed.   Quisling  (Lancet.  Jan.  27.  '94). 

Diagnosis. — This  in  uncomplicated 
cases  is  easy.  The  colored  stools,  the 
pale  urine,  and  the  absence  of  grave 
symptoms  serve  to  distinguish  it  even 
when  severe  from  obstructive  or  septic 
jaundice,  and  from  syphilitic  disease  of 


254 


JAUNDICE.    ICTERUS  NEONATORUM.  ETIOLOGY. 


the  liver,  and  obliteration  of  the  bile- 
duet. 

Literature  of  '96-'97-'98. 

Two  children  of  the  same  mother  died 
of  jaundice.  The  first  pregnancy  ran  a 
normal  course.  The  child  was  healthy 
during  the  first  four  weeks  of  life,  but 
at  that  period  icterus  developed,  and  con- 
tinued up  to  the  time  of  the  child's  death, 
which  occurred  on  the  first  week  of  the 
seventh  month.  The  liver  was  enlarged 
during  life.  There  was  a  small  abdomi- 
nal effusion.  During  the  second  preg- 
nancy the  mother  was  jaundiced  two 
weeks  prior  to  her  confinement.  The 
offspring  became  jaundiced  in  the  third 
month.  The  jaundice  fluctuated  and  at 
times  quite  disappeared.  The  child  grad- 
ually failed  and  died.  At  the  autopsy 
the  liver  resembled  that  of  acute  yellow 
atrophy.  In  the  red  stage  the  kidney 
showed  an  advanced  fatty  degeneration. 
The  pulp  of  the  spleen  was  much  hyper- 
trophied.  Brandenberg  (Centralb.  f.  in- 
nere  Med.;   Inter.  Med.  Mag.,  Dec,  '97). 

Etiology.  —  It  is  of  very  uncertain 
causation;  many  theories  have  been  ad- 
vanced to  explain  it.  Some  have  said 
that  the  condition  is  not  a  true  jaundice, 
but  pigmentation  due  to  rapid  destruc- 
tion of  red  corpuscles  in  the  first  days 
after  birth.  The  presence  of  bile-pig- 
ment and  bile-acids  in  the  pericardial 
fluids  of  icteric  infants  and  not  in  others 
proves,  however,  the  yellow  discoloration 
to  be  due  to  bile,  and  bile  is  always  the 
product  of  the  liver-cell. 

That  the  blood-destruction  leads  to  a 
greater  amount  of  pigment  in,  and  in- 
spissation  of,  the  bile  followed  by  partial 
stasis,  and  consequent  absorption  from 
the  biliary  radicles,  is  probably  the  most 
reasonable  theory.  The  causes  may,  how- 
ever, be  various,  and  several  may  be 
active  in  the  same  case. 

Undissolved  biliary  coloring  matter 
and  bile-salts  arc  always  to  bo  found  in 
the  mine  of  icteric  newborn  infants, 
w  hich  proves  the  hepatogenic  origin  of 


the  disease.  Halberstam  (Jahrbiich  f. 
Kinderh.  u.  phys.  Erzie.,  B.  27,  H.  4,  '88). 

Icterus  neonatorum  is  ascribed  by  sev- 
eral authors  to  late  section  of  the  cord, 
whereby  a  greater  mass  of  blood  is 
thrown  from  the  placenta  into  the  child's 
circulation,  and  a  great  destruction  of  red 
corpuscles  and  coloring  matter  ensues, 
followed  by  icterus.  To  test  this  view, 
50  children  were  at  once  separated  from 
the  cord  at  birth,  and  100  later,  mostly 
after  separation  of  the  placenta.  Of  the 
50,  36  became  icteric  and  14  remained 
unaffected.  Of  the  100,  71  were  observed; 
out  of  these,  30  were  icteric  and  41  re- 
mained well.  The  intensity  of  color  and 
length  of  duration  of  the  jaundice  were 
more  marked  in  those  early  separated 
than  in  others.  Schmidt  (Archiv  f. 
Gynak.,  B.  xlv,  H.  2,  '93). 

Literature  of  '96-'97-'98. 

The  red  corpuscles  bear  no  etiological 
relation  to  icterus  neonatorum.  The 
number  of  erythrocytes  during  the  first 
week  of  life  is  independent  of  the  occur- 
rence of  jaundice.  The  fluctuations  in 
particular  are  more  dependent  upon  the 
changes  in  the  volume  of  plasma.  The 
"resistance"'  of  the  red  corpuscles  is  the 
same  at  the  time  of  birth  as  in  the  adult, 
and  it  is  not  altered  in  consequence  of 
jaundice.  Knopfelmacher  (Wien.  klin. 
Woch.,  Xo.  43,  '96). 

Icterus  neonatorum  is  due  to  patho- 
logical causes  supervening  during  the 
first  moments  of  extra-uterine  life,  and 
not  to  physiological  conditions  attending 
the  birth  of  the  child. 

On  examining  the  liver  in  fatal  cases 
venous  stases  and  retention  of  bile  in  the 
bile-ducts  was  always  present.  The  re- 
tention of  bile  is  favored  by  anything 
which  tends  to  prevent  the  full  expansion 
of  the  lungs,  or  interferes  with  the  free 
action  of  the  heart,  both  of  which  condi- 
tions so  frequently  follow  after  a  difficult 
labor.  The  jaundice  develops  most  fre- 
quently about  the  third  day.  never  ap- 
pearing as  early  as  the  first,  and  rarely 
delayed  as  late  as  the  fifth  day.  The 
duration  of  the  illness  is  from  six  to  four- 
teen days,  and  occurs,  according  to  the 
author's  investigations.  395  times  out  of 
1000  newborn  children.    The  icteric  tint 


JAUNDICE,  ACUTE  INF: 


'ECTIOUS.  SYMPTOMS. 


255 


is  first  observed  on  the  nose  and  cheeks, 
and  occasionally  the  face  alone  is  jaun- 
diced, the  rest  of  the  body  remaining  of 
a  normal  color.  The  color  of  the  urine  is 
unchanged  in  mild  cases,  but  in  severer 
attacks  bile-pigment  is  present.  There  is 
often  profound  alteration  of  nutrition 
and  slowing  of  the  pulse-rate  during  an 
attack.  Vermel  (Presse  Med.  Beige., 
June  1,  '98). 

Weil's  Disease  (Acute  Infectious 
Jaundice) . 

In  1886  Weil  described  "  A  peculiar 
form  of  acute  infectious  disease  charac- 
terized by  jaundice,  swelling  of  the 
spleen,  and  nephritis."  This  has  been 
recognized  by  German  writers  as  a  new 
disease.  But  others  have  looked  upon  it 
only  as  what  has  long  been  described  as 
"acute  infectious  jaundice,"  a  name  that 
serves  sufficiently  to  designate  it. 

Symptoms. — The  disease  presents  the 
symptoms  that  characterize  acute  infec- 
tions generally.  It  sets  in  suddenly, 
usually  with  chill,  followed  by  fever, 
pain  in  the  back  and  limbs,  loss  of  appe- 
tite, thirst,  general  malaise,  headache, 
giddiness,  and  usually  diarrhoea.  The 
symptoms  increase  for  a  day  or  two,  the 
temperature  rising  rapidly  to  104°  or 
105°  F.,  weakness  increases,  and  there  is 
mild  delirium.  Jaundice  appears  on  the 
second  or  third  day,  with  marked  en- 
largement and  tenderness  of  the  liver 
and  swelling  of  the  spleen.  The  urine 
becomes  albuminous  and  shows  the  other 
.signs  of  acute  nephritis.  There  is  marked 
derangement  of  the  digestion — furred 
tongue,  nausea,  and  sometimes  vomiting. 
The  symptoms  begin  gradually  to  subside 
by  the  fifth  to  the  eighth  day.  The  per- 
sistent high  temperature  falls,  gradually 
reaching  the  normal  by  the  tenth  or 
twelfth  day.  The  jaundice  abates  with 
the  other  symptoms. 

Epidemic  of  icterus  occurring  especially 
among  children  noted.  Reports  of  518 
cases  collected   in   Saxony   during  the 


autumn  of  1889.  The  initial  stage  lasted 
three  or  four  days  and  was  characterized 
by  fever,  vomiting,  constipation,  and 
congestion  of  liver  and  spleen.  The 
icteric  stage  appeared  one  or  two  days 
after  defervescence  and  lasted  about 
eleven  days.  Seventy-three  per  cent,  of 
the  children  living  in  the  region  where 
the  epidemic  prevailed  were  attacked. 
Thirteen  deaths  were  reported  to  the 
writer.  Catarrhal  conditions  of  the 
stomach  did  not  predispose  to  the  disease, 
while  disorders  of  the  respiratory  tract, 
and  especially  influenza,  did.  It  appeared 
to  be  both  contagious  and  miasmatic. 
Meinert  (La  Semaine  Med.,  Aug.  27,  '90). 

Small  epidemic  of  icterus  among  chil- 
dren attending  the  same  school,  but  liv- 
ing in  houses  far  apart.  The  attack  com- 
menced suddenly,  with  vomiting,  pros- 
tration, headache,  vague  gastric  pains, 
and,  in  the  course  of  three  or  four  days, 
intense  icterus.  The  whole  process  lasted 
ten  to  twelve  days.  Denton  (Revue  Med. 
de  la  Suisse  Rom.,  Oct.,  '90). 

In  9  cases  of  infectious  icterus  (Weil's 
disease),  uraemia  occurred  in  2  cases,  1 
fatal.  Haemorrhages  were  frequent,  espe- 
cially from  the  skin  and  nose.  Suppura- 
tive otitis  media  occurred  in  1  case.  Re- 
currence in  1  instance  followed  an  afebrile 
period  of  six  days.  Croupous  pneumonia 
developed  in  1  case,  with  fatal  ending. 
In  the  third  fatal  case  death  was  due  to 
the  severity  of  the  infection.  Munzer 
(Zeitschrift  f.  Heilkunde,  B.  12,  H.  2,  3, 
'92). 

Two  cases  of  infectious  jaundice  in 
neither  of  which  was  there  obstruction 
of  the  bile-ducts.  Toxic  cases  of  this 
nature  may  become  malignant  through 
renal  complications,  which,  in  turn,  react 
upon  the  liver.  Rendu  (Le  Bull.  Med., 
May  28,  '93). 

An  infectious  icterus  resembling  ty- 
phoid in  its  clinical  appearance.  The 
phenomena  are  ushered  in  with  pain  in 
the  head  and  limbs,  the  temperature 
gradually  rising  till  it  reaches  102.2°  to 
103°  F.,  which  height  continues  five  to 
eight  days.  On  the  fourth  or  fifth  day 
icterus  appears,  the  spleen  is  enlarged, 
and  the  margin  of  the  liver  is  prominent 
and  painful.  The  tongue  is  coated.  The 
urine  contains  albumin  from  the  begin- 


256        JAUNDICE,  ACUTE  INFECTIOUS. 


ETIOLOGY.    MORBID  ANATOMY. 


ning,  but  becomes  dark  on  the  fourth  day, 
although  the  faeces  are  normal  and  some- 
times colorless.  The  duration  of  the  dis- 
ease is  between  two  and  three  weeks.  It 
usually  terminates  in  recovery.  Two 
fatal  cases,  however,  are  on  record.  The 
necropsies  revealed  great  reddening  and 
swelling  of  the  solitary  follicles.  Hoep- 
pener  (Med.  Press  and  Circular,  July  23, 
'93). 

Literature  of  '96-'97-'98. 

Three  cases  of  contagious  icterus  in 
children,  all  of  whom  presented  the  same 
symptoms, — anorexia,  fever,  and  icterus, 
— which  set  in  after  the  decline  of  the 
fever  and  which  continued  only  for  a  few 
days.  Two  of  the  children  belonged  to  the 
same  class  in  school  and  the  third  came 
daily  in  contact  with  the  first  child. 
Ulrik  (Ugeskrift  for  Lager,  p.  265,  '96). 

Convalescence  is  usually  uninter- 
rupted, but  in  a  certain  number — about 
one-fourth — the  fever  recurs  within  a 
week,  lasting  five  or  six  clays,  in  only  a 
few  cases  being  accompanied  by  recur- 
rence of  jaundice,  swelling  of  the  liver 
.and  spleen,  and  albuminuria. 

Convalescence  is  always  slow,  the 
.strength  not  being  restored  for  many 
weeks. 

Of  the  symptoms,  the  most  marked 
usually  are  the  muscular  pains,  especially 
in  the  calves  of  the  legs.  The  pains  may 
be  so  severe  as  to  obscure  the  other  symp- 
toms. They  are  much  increased  by 
movement  and  by  pressure  of  the 
muscles. 

Etiology.— It  is  met  with  usually 
among  males  between  the  ages  of  fifteen 
and  thirty  years,  but  has  been  seen  in 
children  as  young  as  eight.  It  occurs 
usually  in  endemic  outbreaks  in  summer, 
.affecting  chiefly  workmen  engaged  in  in- 
sanitary occupations  or  environments. 
It  is  rare  in  America.  It  doubtless  be- 
longs to  the  group  of  toxannie  jaundice, 
bul  as  to  the  nature  of  the  infection, 
whether  specific  or  multiple,  is  still  to  be  ' 


determined.  In  two  out  of  three  fatal 
cases  Jaeger  found  a  bacillus  of  definite 
characters  in  the  organs  of  the  body,  and 
in  the  urine  of  four  out  of  six  cases  that 
recovered,  the  same  organism  was  found. 
Ducks  and  geese — frequenting  the  river 
in  which  these  cases  were  supposed  to 
have  acquired  the  disease  by  bathing — 
were  subject  to  a  fatal  form  of  jaundice, 
and  in  them  similar  post-mortem  changes 
and  the  same  organism  were  found. 

It  seems  proved  by  the  experience  of 
military  surgeons  that  jaundice  may  be 
a  specific  infectious  malady  developed  in 
marshy  regions  and  in  much  the  same 
surroundings  as  those  which  produce 
malaria  or  typhoid  fever.  Parmentier 
(Gaz.  des  Hop.,  p.  1142,  '87). 

Thirty-four  epidemics  of  jaundice,  all  of 
which  were  purely  local,  confined  to  one 
place  or  part  of  a  place,  such  as  a  camp, 
barracks,  works,  or  even  a  house.  Hirsch 
(Geography  of  Disease,  '88). 

Group  of  cases  of  epidemic  jaundice, 
eleven  in  number,  which  occurred  in  five 
families  living  in  Parkhead.  Glasgow. 
Russell  (Brit.  Med.  Jour.,  Aug.  11.  '88). 

Infectious  icterus  is  a  general  acute 
specific-infectious,  miasmatic,  non-con- 
tagious disease.  It  may  be  sporadic,  epi- 
demic, or  endemic,  and.  as  a  rule,  runs  a 
favorable  course.  It  stands,  in  some  way, 
in  a  certain  relation  to  typhoid  fever  and 
to  typhus  biliosus.  The  infection-  agent 
arises  outside  of  the  human  body.  The 
disease  never  relapses.  Hennig  (Volk- 
mann's  Sammlung  klin.  Vort..  No.  8.  '90). 

Infectious  icerus  due  to  a  proteus  in- 
fection. Doubts  concerning  Banti'a  new- 
bacillus.  Jaeger  (Deutsche  med.  YVoch., 
Oct.  3,  '05). 

Case  showing  analogy  between  Weil's 
disease  due  to  proteus  and  icterus  neona- 
torum. Bar  and  Renon  (Comptes  Ren- 
dus  Hebd.  des  Seances,  etc.,  May  24.  '05). 

Morbid  Anatomy. — The  liver-chai 
resemhle  those  found  in  acute  yellow 
atrophy,  bul  to  a  much  less  degree. 
There  is  fatty  degeneration  and  cloudy 
swelling  of  the  renal  epithelium,  or  even 
an    acute    parenchymatous  nephritis. 


JAWS.  ALVEOLAR 


ABSCESS.  EPULIS. 


257 


Minute  haemorrhages  exist  in  various 
organs  and  on  the  serous  surfaces.  The 
spleen  is  swelled.  There  are  no  traces  of 
typhoid  ulceration. 

Prognosis. — Only  a  small  number  of 
cases  have  terminated  fatally,  but  con- 
valescence is  protracted. 

Treatment. — This  is  quite  symptom- 
atic. The  pains  will  require  anodyne  for 
their  relief. 

Alexander  McPhedran, 

Toronto. 

JAWS,  DISEASES  OF. 
Alveolar  Abscess,  or  "Gum-boil." 

A  gum-boil  usually  begins  in  the 
socket  of  a  carious  tooth.  It  is  generally 
quite  superficial,  and  gives  rise  to  but 
few  external  signs,  but  occasionally,  espe- 
cially when  due  to  a  disorder  at  the  root 
of  a  tooth,  the  active  manifestations  are 
accompanied  by  severe  throbbing  pain, 
considerable  swelling  of  the  cheek  of  the 
corresponding  side,  and  with  protrusion 
of  the  tooth  from  thickening  of  the  peri- 
dental tissues.  When  the  lateral  incisors 
are  involved,  the  abscess  may  spread  pos- 
teriorly between  the  layers  of  the  hard 
palate,  or  anteriorly  in  the  direction  of 
the  nose,  opening  into  the  latter.  When 
the  molars  are  involved,  it  may  penetrate 
the  tissues  of  the  face,  thus  leaving  a 
sinus  or  scar.  Necrosis  and  pyaemia  have 
occurred  in  rare  instances  as  complica- 
tions.- 

Treatment.  —  The  old-fashioned  lin- 
seed-meal poultice  is  worse  than  useless; 
it  lends  to  encourage  the  inflammatory 
process  and  to  involve  the  cheek.  Hot 
water  as  hot  as  can  be  borne  held  in  the 
mouth  is  Ear  better.  Painting  the  gums 
with  a  10-per-cent.  solution  of  cocaine  is 
sometimes  temporarily  effective  in  mild 
cases.  Free  leeching  or  lancing  can  be 
resorted  to  if  the  abscess  progresses. 
Leeches  should  always  be  applied  through 

4- 


leech-glasses,  and  not  wrapped  in  a  nap- 
kin, as  often  done.   If  these  measures  do 
not  suffice  the  patient  should  consult  a 
dentist. 
Epulis. 

Although  applied  to  various  neoplasms 
of  the  gums,  the  term  "epulis"  is  only 
applicable  to  a  growth  of  the  alveolar 
process  and  tooth-sockets.  Two  varieties 
of  epulis  are  recognized:  the  simple,  or 
benign;  and  the  malignant. 

Simple  Epulis. — A  benign  epulis  is, 
in  reality,  a  fibroma:  a  smooth,  rounded 
projection  of  the  gum,  usually  beginning 
between  two  teeth,  which  it  gradually 
separates,  displaces,  and  loosens.  It  may 
involve  several  teeth  and  involve  the  pos- 
terior or  the  anterior  aspect  of  the  alve- 
olus. It  is  painless,  of  slow  and  indolent 
growth,  but,  if  left  to  itself,  it  ulcerates 
and  causes  marked  deformity.  It  some- 
times ossifies. 

Malignant  Epulis. — This  is  a  much 
more  dangerous  variety.  Beginning 
usually  at  the  socket,  it  is  characterized 
by  the  presence  of  irregular  multinucle- 
ated mass  of  giant-cells  associated  either 
with  round  or  spindle  cells,  or  both.  It 
is  really  a  myeloid  sarcoma.  It  is  exceed- 
ingly vascular,  purplish  red,  grows  much 
more  rapidly  than  the  simple  epulis,  and 
is  finally  transformed  into  a  spongy  mass, 
which  projects  in  various  directions  and 
bleeds  upon  the  least  contact  with  a  hard 
substance. 

Out  of  1156  tumors  that  have  been  ex- 
amined during  the  last  eleven  years  at 
the  Laboratory  of  Nantes,  32  have  been 
epulis.  Of  these,  4  were  in  patients  of  5 
to  15  years,  12  of  15  to  40  years,  8  of  40 
years  and  upward.  Eighteen  tumors  were 
removed  from  females  and  5  from  males ; 
9  were  seated  in  the  lower  jaw,  and  7  in 
the  upper.  There  is  no  evidence  of  its 
ever  being  epitlieliomatous.  Nine  were 
h  ue  fibromaSj  (>,  however,  being  partly 
myxomatous.  Sarcoma  is  the  commonest 
form,  this  being  typically   myeloid  in 

17 


258 


JAWS.  NECROSIS. 


character.  De  Larabrie  (Archives  Gen. 
de  Med.,  Jan.,  '89). 

Epulis  regarded  as  a  recurring  tumor 
of  malignant  character  and  tending  to 
destroy  life.  It  seems  to  be  definitely 
settled  that  epulis  belongs  to  the  sar- 
comatous group.  It  is  a  myeloid  sar- 
coma, composed  of  fibrous  tissue  and 
myeloid  cells,  the  former  predominating, 
and  it  would  appear  occasionally  to  exist 
almost  to  the  exclusion  of  the  latter,  and 
rice  versa.  The  greater  the  preponder- 
ance of  myeloid  cells,  the  greater  the 
tendency  to  malignancy.  Early  removal 
means  a  cure.  When  neglected  the  tend- 
ency is  to  destroy  life.  W.  B.  Rogers 
(Memphis  Jour,  of  Med.  Sci.,  Apr.,  '90). 

Myeloid  epulis  may  ossify.  I.  Hutchin- 
son, Jr.  (Lancet,  Apr.  5,  '90). 

Treatment  of  Epulis. — Whether  the 
growth  present  be  a  simple  or  malignant 
one,  the  sooner  it  is  removed  the  better. 
The  tumor,  and  the  tooth  or  teeth  and 
the  portion  of  the  alveolar  process  in- 
volved, should  be  cut  out,  this  constitut- 
ing the  only  safe  mode  of  treatment. 
Mere  scraping  is  followed  by  a  return  of 
the  tumor  in  almost  every  case,  whether 
simple  or  malignant.  The  portions  of 
bone  to  be  removed  being  mapped  out, 
two  vertical  incisions  are  made  with  a 
Hey  saw,  and  the  diseased  mass  is  re- 
moved with  forceps,  after  having  been 
dissected  from  its  surroundings. 

Four  cases  of  epulis  personally  operated 
upon,  in  all  of  which  an  attempt  had 
been  made  to  remove  the  growth  without 
sacrificing  the  teeth,  and  in  all  there  was 
prompt  recurrence.  Thus  far  the  prompt 
removal,  after  drawing  the  teeth  from 
whose  base  the  tumor  had  sprung,  lias 
been  effectual,  and  was  likely  to  continue 
so.  All  cases  of  tumor  of  this  kind  re- 
moved at  the  hospital  from  1S7S  to  1SSS 
have  been  followed,  and  neither  recur- 
rence nor  death  has  occurred.  Where  the 
growth  appears  on  both  sides  of  the 
alveolar  process,  at  least  one  of  the  teeth, 
and  often  both,  must  be  drawn  to  give 
free  access  to  the  periosteum.  In  this  dis- 
ease the  dangers  of  palliative  delay  are 
not  great,  on  account  of  the  fact  that  it  1 


has,  in  the  beginning,  at  least,  only  local 
malignancy.  M.  H.  Richardson  (Boston 
Med.  and  Surg.  Jour.,  Oct.  2,  '90). 

Conclusions  from  observations  of  epu- 
lis: 1.  In  none  of  personal  cases  of  epulis 
have  evidences  of  general  or  secondary 
invasion  been  observed,  and  it  has  been 
sufficient  to  remove  the  tumor  and  to  ex- 
tract the  roots  or  teeth  with  which  they 
were  connected  to  cause  the  arrest  of  the 
disease.  2.  In  all  cases  treated  there  has 
been  a  great  neglect  of  the  hygiene  of  the 
mouth.  This  has  been  the  case  especially 
with  persons  working  in  copper,  or  cut- 
lers, whose  teeth  accumulate  a  character- 
istic tartar  which  appears  to  predispose 
them  especially  to  these  neoplastic  forma- 
tions. F.  D.  Rodriguez  (Cronica  Medico- 
quir.  de  la  Habana,  Oct.,  '90). 

Necrosis. 

Necrosis  of  the  jaw  may  be  due  to  any 
condition  liable  to  give  rise  to  inflamma- 
tion of  its  periosteum  by  injury  due  to 
extraction  of  teeth,  by  various  suppura- 
tive diseases,  the  acute  exanthemata, 
pyaemia,  actinomycosis,  etc.,  or  by  the 
action  of  various  diathetic  processes,  such 
as  syphilis,  tubercle,  or  leprosy.  It  is 
most  frequently  caused  by  the  fumes  of 
phosphorus  (see  beyond),  and  by  mer- 
cury taken  internally.  Deficient  nutri- 
tion, scorbutus,  or  other  conditions  in 
which  the  organism  is  deprived  of  its 
vital  pabulum  frequently  manifests  ne- 
crosis of  the  jaws  as  a  symptom.  It  may 
thus  occur  at  any  age,  and  does  seem  to 
show  a  predilection  for  either  the  upper 
or  lower  maxillary. 

Necrosis  is  always  preceded  by  deeply- 
seated  and  intense  pain;  the  parts  are 
red,  inflamed,  and  tumefied.  After  a 
time  the  pain  is  somewhat  reduced  and 
sinuses  are  formed,  from  which  a  foetid 
pus  exudes.  The  teeth  are  loosened  and 
fall  out,  and  the  cavity  left  is  bathed  in 
pus.  A  probe  passed  in  any  of  the  si- 
nuses reveals  the  presence  of  dead  bone 
by  conveying  to  touch  the  characteristic 
I  sensation  of  roughness.    Portions  of  the 


JAWS.    PHOSPHORUS  NECROSIS. 


259 


bone  become  detached  and  are  easily 
removed. 

Case  of  a  boy,  aged  6  years,  taken  sick 
with  influenza  in  December,  1889.  Dur- 
ing convalescence  fcetor  and  swelling  of 
the  mucous  membrane  of  the  right  cheek 
noticed.  Fever  set  in  on  the  fourth  day, 
and  a  gangrenous  area  was  noticed  which 
spread  rapidly  to  the  right  half  of  the 
upper  lip  and  invaded  with  special  vio- 
lence the  osseous  portion  of  the  upper 
jaw.  The  whole  of  this  bone  was  com- 
pletely carious.  The  face  on  the  right 
side  presented  an  enormous  cedema,  which 
hid  the  eye  completely.  There  was  an 
abundant  and  foetid  salivation  and  an 
odor  of  cadaveric  putrefaction. 

Complete  excision  of  the  diseased  upper 
jaw  was  performed  by  which  the  whole 
of  the  osseous  lesion  was  removed.  The 
gangrenous  soft  parts  were  partially  re- 
moved and  burned  with  the  Paquelin 
cautery,  and  the  cavity  packed  thor- 
oughly with  iodoform  gauze.  In  two 
months  there  was  complete  recovery 
without  marked  deformity.  Christovitch 
(Bull.  Gen.  de  Ther.,  Nov.  15,  '90). 

Difficult  and  complicated  deformity  of 
the  lower  maxilla,  resulting  from  long- 
standing necrosis  and  caries,  of  doubtful 
origin,  successfully  treated.  The  patient, 
a  male  aged  40  or  45  years,  lost  the  two 
lateral  halves  of  the  lower  jaw.  In  conse- 
quence of  this  the  anterior  portion  of  the 
horseshoe,  formed  by  the  jaw,  which  had 
yet  attached  to  it  the  incisors,  the  ca- 
nines, and  the  molars  of  each  side,  was 
thrown  backward  in  an  inclined  position 
downward,  which  made  it  impossible  for 
the  teeth  to  meet,  and  also  caused  a  very 
ugly  retraction  of  the  chin.  By  means  of 
splints  and  plate,  and  subsequent  modi- 
fications, excellent  results  were  obtained, 
in  spite  of  the  carelessness  of  the  patient 
and  many  obstacles  which  seriously  in- 
terfered  with  the  prothetic  treatment. 
Martin  (T  yon  Med.,  Mar.  27,  '92). 

Phosphorus  Necrosis. 

Symptoms.  —  Phosphorus  necrosis 
comes  on  gradually,  and  sometimes  Inn- 
after  the  patient  lias  been  exposed  to  its 
toxic  influence  in  connection  with  his 
y  occupation,  the  manufacture  of  matches, 


i  etc.  But,  once  started,  it  progresses 
rapidly,  involving  large  areas  of  bone; 
owing  to  the  general  toxaemia,  many 
foci  of  inflammation  may  be  developed  at 
:  once.  The  lower  jaw  seems  to  be  that 
in  which  phosphorus  necrosis  most  fre- 
;  quently  occurs. 

Pain  is  one  of  the  earliest  symptoms; 
at  first  intermittent,  it  soon  becomes  con- 
tinuous.  Suppuration  of  the  perialveolar 
and  peridental  membranes  occurs,  pus 
appears  at  the  alveoli,  and  the  inflamma- 
tion soon  includes  the  gum-structures, 
the  tissues  of  the  face  becoming  infil- 
trated, and  the  characteristic  deformity 
appears.    The  entire  periosteal  layer  is 
then  invaded,  sinuses  are  formed,  open- 
ing into  the  mouth  and  externally  under 
j  the-  lower  maxillary  edge;   and  pus  is 
|  exuded  on  all  sides.    The  pain  becomes 
|  less  marked  when  this  stage  is  reached, 
;  unless  the  necrotic  process  involve  the 
condyle,  when  severe  pain  in  the  ear  is 
experienced. 

The  general  health  of  the  patient  soon 
suffers  considerably.  The  constant  dis- 
charge, the  presence  of  offensive  pus  in 
the  mouth  and  stomach  (much  of  the  dis- 
j  charge  being  swallowed),  the  occlusion 
of  the  jaws  through  infiltration  of  the 
maxillary  muscles  and  the  impediment 
to  the  ingestion  of  food,  combine  to 
rapidly  bring  on  exhaustion  and  death 
unless  proper  treatment  be  instituted. 

In  some  cases,  however,  the.  process  is 
a  slow  one,  and  comparative  health  is 
enjoyed  while  now  and  then  a  necrotic 
sequestrum  is  discharged  through  cue  of 
the  sinuses. 

In  some  operatives,  however,  a  special 
susceptibility  to  phosphorus  exists,  and 
acute  symptoms — nausea  and  vomiting, 
etc. — indicates  an  acute  poisoning  that 
requires  immediate  cessation  of  all  work 
in  which  phosphorus  is  handled  or  in- 
|  haled. 


260 


JAWS.    PHOSPHORUS  NECROSIS.  TREATMENT. 


Etiology  and  Pathology. — The  inhala- 
tion of  the  vapor  of  phosphorus  and 
the  particles  of  this  substance  taken  in 
with  the  food  when  the  hands  are  not 
properly  cleansed  and  improper  care  of 
the  teeth  combine  to  very  gradually 
bring  on  the  general  toxaemia.  This,  in 
turn,  gives  rise  to  slow  disintegration  of 
the  red  blood-corpuscles  and  fatty  de- 
generation of  the  arterial  coats.  That 
the  maxillary  bones  should,  of  the  entire 
osseous  system,  bear  the  brunt  of  the  dis- 
ease demonstrates  that  a  local  factor  must 
play  a  prominent  part  in  the  disease.  It 
is  thought  that  the  peridental  membrane 
laid  bare  by  accumulation  of  tartar,  and 
whose  vascular  supply  is  already  diseased 
by  the  general  toxaemia,  is  easily  influ- 
enced by  any  phosphorus  that  may  enter 
the  mouth,  and  thus  readily  yields  to  the 
irritation  induced,  carious  teeth  and 
other  infectious  foci,  and  that  the  ne- 
crotic process  follows  the  local  inflamma- 
tion engendered. 

Treatment.  —  In  the  early  stages  the 
teeth  should  receive  careful  attention, 
carious  ones  being  extracted,  while  the 
tartar  around  those  not  diseased  should 
be  carefully  removed.  These  manipula- 
tions should  be  conducted  antiseptically, 
strict  care  of  the  teeth  following. 

Turpentine,  according  to  Hohler  and 
Schimpf,  when  exposed  some  time  to 
the  air  becomes  rich  in  ozone,  and  pre- 
vents fatty  degeneration.  Theoretically, 
it  is  thus  capable  of  neutralizing  the 
effects  of  phosphorus:  a  po.wer  which 
has  a  No  been  demonstrated  practically. 
Andant  found  that  it  arrested  the  vapor 
of  phosphorus  in  the  dark.  The  ordi- 
nary American  oil  of  turpentine  is  of  no 
value,  however,  unless  it  be  long  exposed 
to  the  air.  It  is  to  be  administered  in- 
ternally and  by  inhalation.  Potassium 
permanganate  is  also  a  valuable  antidotal 
ao-ent.     The  oeneral  health  should  be 


I  carefully  watched  and  every  means  used 
to  facilitate  increased  nutrition  by  the 
use  of  tonics  and  easily-digested  foods. 

In  the  stage  of  ulceration  antiseptic 
washes  as  warm  as  possible  should  be  fre- 
quently used.  A  weak  permanganate-of- 
potassium  solution  is  particularly  valu- 
able in  this  connection,  when  syringed 
into  the  sinuses.  This  being  done,  iodo- 
form gauze  can  be  packed  in  to  absorb 
secretions  to  avoid  their  mixture  with 
food.  Sequestra  should  be  removed  when 
free,  and  the  cavity  packed.  Mears  ad- 
vises that,  when  the  lower  jaw  is  involved, 
but  half  of  the  ramus  should  be  removed 
at  one  time,  to  preserve  the  contour  of 
the  parts.  After  the  expiration  of  eight 
or  ten  weeks  the  remaining  portion  may 
be  removed. 

New  method  of  operating  in  the  treat- 
ment of  phosphorus  necrosis  of  the  lower 
jaw.  Two  sittings  are  required  for  opera- 
tion. In  the  first  operation  an  incision 
is  made  along  the  lower  border  of  the 
jaw,  by  which  all  the  soft  parts,  includ- 
ing the  periosteum,  are  incised  to  the 
bone;  the  periosteum  is  completely  de- 
tached, together  with  the  osteophytic 
buyer,  until  the  necrosed  bone  remains 
bare.  A  very  thin  layer  of  iodoform 
gauze  is  then  introduced  between  the 
bone  and  the  periosteum.  Five  weeks 
later  the  necrotic  bone  is  excised.  Dur- 
ing this  time  the  periosteum  has  become 
a  firm  bony  capsule,  which  has  the  shape 
of  the  jaw,  so  that  outline  of  the  maxilla 
is  preserved  after  the  removal  of  the  se- 
questrum. K.  Jervell  (Norsk  Mag.  for 
Laegevid.,  '89). 

Case  of  phosphorus  necrosis  of  the  left 
superior  maxilla,  in  which  the  necrosed 
jaw  was  successfully  removed  by  sub- 
periosteal and  intrabucca]  operation. 
Fusci  (Riforma  Med..  Apr.  27.  '91). 

Value  of  hydrogen  peroxide  extolled  in 
the  treatment  of  alveolar  necrosis  of 
jaws.  Cassel  (Deut.  med.  Woch.,  p.  554, 
'89). 

When  the  patient  cannot  avoid  ex- 
I  posnre  to  phosphorns-fnmes.  the  pre- 


JEQUIRITY. 


PHYSIOLOGICAL  ACTION. 


POISONING. 


261 


ventive  measures  should  consists  in  free 
ventilation,  absolute  cleanliness,  espe- 
cially of  the  mouth  and  hands,  and  dis- 
engagement of  the  vapor  of  turpentine  in 
working-rooms.  Cloths  may  be  soaked 
in  this  substance  and  spread  out  close  to 
where  the  exposed  subject  is  working. 

JEQUIRITY.— Jequirity  is  the  Bra- 
zilian name  given  to  the  seeds  of  the 
Abrus  precatorius.  Abrus,  or  wild  lico- 
rice, one  of  the  leguminosse,  is  a  climbing 
shrub  indigenous  to  India,  but  now 
naturalized  elsewhere  in  the  tropics.  The 
seeds,  or  beans,  are  small,  nearly  round, 
of  a  bright-red  color,  with  a  black  spot 
at  the  hilum,  are  inodorous,  and  have  a 
slight  bean-like  taste.  They  are  em- 
ployed in  India  as  a  standard  weight 
(about  1  1/2  grains).  Warden  and  Wad- 
dell,  of  Calcutta,  claim  that  the  seeds  are 
inert  when  taken  whole  into  the  stom- 
ach. The  seeds  contain  abric  acid  and  an 
albuminoid  active  principle  (abrin), 
which  is  composed  of  paraglobin  and 
alpha-phytalbumose,  which  closely  re- 
semble snake-venom  in  their  action, 
though  less  powerful.  Abrin  occurs  as  a 
brownish-yellow  powder,  soluble  in  cold 
water  and  in  glycerin.  It  is  precipitated 
from  aqueous  and  glycerin  solutions  by 
alcohol.  Abrin  is  a  powerful  cardiac 
poison.  The  root  of  the  plant  is  official 
in  the  Pharmacopoeia  of  India  as  a  sub- 
stitute for  licorice. 

Physiological  Action. — Klein  has 
shown  that  the  poisonous  properties  of 
jequirity  cannot  be  due  to  a  bacillus, 
while  Warden  and  Waddell  found  it  to 
be  due  to  the  action  of  a  poisonous  pro- 
tcid.  The  proteids  in  the  seeds  are  two 
in  number:  a  globulin  and  an  albumose. 
S.  Martin  and  R.  N.  Wolfenden  found 
that  globulin  produces  local  oedema  and 
inflammation  when  subcutaneously  in- 
jected or  applied  to  the  eye  (with  post- 


mortem petechias  beneath'  the  serous 
membranes),  and  hemorrhagic  gastro- 
enteritis. It  also  causes  a  remarkable  fall 
of  body-temperature  after  subcutaneous 
injection,  and  in  lethal  doses  it  causes 
rapidity  of  breathing  shortly  before 
I  death.  It  has  little  or  no  effect  on  blood- 
pressure.  The  activity  of  this  globulin 
is  destroyed  by  heating  the  solution  to 
75°  or  80°  F.:  the  temperature  at  which 
it  enters  into  a  condition  of  heat-coagu- 
lum.  Martin  also  found  that  the  symp- 
toms produced  by  the  albumose  closely 
resemble  those  noticed  when  the  globulin 
is  hypodermically  injected.  There  is 
gradually  -  increasing  weakness,  with 
rapid  breathing  and  lowering  of  body- 
temperature,  but  no  convulsions  or  pa- 
ralysis. It  also  causes  severe  conjunc- 
tivitis when  applied  to  the  eye.  Its 
poisonous  properties  are  lessened  by 
heating  at  70°  to  75°  F.,  and  completely 
destroyed  at  85°  F.  The  albumose  is  not, 
however,  so  powerful  a  toxic  agent  as  the 
globulin,  the  dose  necessary  to  produce 
the  same  effects  being  larger.  A  simi- 
larity between  the  action  of  the  proteids 
and  those  of  other  poisonous  substances 
of  the  same  class,  especially  those  in 
snake-venom,  is  suggested. 

Poisoning"  by  Jequirity.  —  An  acute 
conjunctivitis  follows  the  topical  appli- 
cation of  the  infusion  or  powdered  seeds. 
While  pounding  the  seeds  one  is  liable 
to  an  attack  of  conjunctivitis,  rhinitis,  or 
bronchitis,  and  any  cuts  or  scratches  on 
the  fingers  become  swollen,  painful,  and 
the  centre  of  an  erythematous  blush. 
The  careless  handling  of  abrin  is  ex- 
tremely dangerous  to  the  eye  and  the 
nose,  and  the  smallest  particle  may  be 
fatal  in  the  slightest  wound.  Abrin  is 
not  used  internally;  it  is  very  poisonous, 
Vioo  grain  being  a  fatal  dose  for  a  man  of 
130  pounds  in  weight.  The  lethal  symp- 
toms of  the  internal  use  or  hypodermic 


2G2 


JEQUIRITY.  THERAPEUTICS. 


JOINTS. 


injection  of  'abrin  are  faintness,  vertigo, 
vomiting;  cold,  clammy  surface;  dysp- 
noea; small,  frequent,  irregular  pulse; 
convulsions,  and  collapse.  Death  occurs 
from  cardiac  paralysis. 

Albuminous  principle  isolated  from 
Ahrus  precatorius,  which  is  100  times 
more  poisonous  than  strychnine,  and 
acts  in  the  same  manner  on  the  system 
as  the  poisonous  principle  extracted  from 
castor-oil  seeds.  Death  is  caused  by  the 
coagulation  of  the  blood-corpuscles. 
Robert  (Ther.  Gaz.,  Feb.,  '90). 

Treatment  of  Abrin  Poisoning. — Car- 
diac stimulants,  digitalis,  amyl-nitrite, 
ammonia,  and  whisky  are  to  be  exhib- 
ited, and  external  warmth  applied. 

Therapeutics. — In  this  country  jequir- 
ity has  never  been  used  internally  in 
medicine.  At  present  the  use  of  jequirity 
is  limited  to  those  obstinate  cases  of  gran- 
ular conjunctivitis  and  pannus,  especially 
the  latter,  which  have  resisted  other 
modes  of  treatment.  Its  action  is  chiefly 
by  replacing  an  existing  inflammation  by 
another  of  stronger  type,  but  of  tempo- 
rary duration.  Although  jequirity  is  said 
to  have  been  used  in  Brazil  for  centuries 
as  a  popular  remedy  for  granular  cystitis 
and  pannus,  it  was  de  Wecker,  of  Paris, 
who,  in  1882,  revived  interest  in  the 
remedy  by  the  publication  of  reports  of 
its  successful  use  in  his  practice.  He 
recommends  its  use  as  follows:  Powder 
32  jequirity-berries  and  macerate  them 
for  twenty-four  hours  in  one  pint  of  cold 
water;  add  an  equal  quantity  of  hot 
wafer,  and  filter  when  cool.  Sattler  ad- 
vises that  the  husks  of  the  seeds  be  re- 
moved by  means  of  hot  water  before  the 
infusion  is  made.  The  seeds  are  then 
powdered  and  6  lluidounces  of  hot  water 
added.  This  infusion  is  allowed  to  stand 
for  twenty-four  hours,  when  it  is  filtered. 
Andrews  recommends  that  the  husks  be 
rejected,  the  berries  ground  and  macer- 
ated for  twelve  hours  in  cold,  distilled 


water,  and  that  then  the  infusion  be  fil- 
tered, care  being  taken  that  the  prepara- 
tion be  made  in  a  clean  Vessel  and  the 
maceration  be  conducted  in  a  cool  place. 
In  any  case,  the  solution  should  be  used 
while  fresh.  Decomposition  renders  it 
unfit  for  use,  and  dangerous. 

Any  one  of  the  above  infusions  being 
selected,  a. portion  is  painted  on  the  con- 
junctival surface  of  the  eyelid  with  a 
brush.  This  procedure  is  followed  by 
an  acute  diphtheritic  inflammation,  last- 
ing three  or  four  days,  and  attended  with 
fever  and  pain  in  the  eyes  and  in  the 
frontal  region.  This  so  changes  the 
chronic  process  present  as  to  permit  of  a 
cure.  If  an  excessive  action  is  developed, 
it  may  be  controlled  by  hot  compresses 
made  of  very  dilute  solutions  of  corrosive 
sublimate  (Hare).  If  the  first  applica- 
tion gives  rise  to  but  slight  reaction,  it 
may  be  repeated  after  an  interval  of 
twenty-four  hours. 

De  Wecker  reported  that  the  jequirity 
inflammation  was  peculiar  in  that  it  did 
not  tend  to  spread  to  the  cornea  or  other 
tissues,  but  was  confined  to  the  conjuncti- 
val sac  to  which  it  had  been  applied.  In- 
stances, however,  have  been  reported 
where  the  inflammation  spread  to  the 
face,  neck,  and  the  upper  part  of  the 
chest.  Warren  and  Waddell  report  a 
case  of  sloughing  of  the  cornea  from  a 
single  application  of  a  somewhat  con- 
centrated infusion  of  the  seeds.  An  in- 
fusion (3  per  cent.),  prepared  with  cold 
distilled  water,  prepared  fresh,  and  used 
while  fresh,  is  advised. 

Purulent  conjunctivitis  contra-indi- 
cates  the  use  of  jequirity. 

C.  Sumner  Witiierstixe, 

Philadelphia. 

JOINTS,  SURGICAL  DISEASES  OF. 

Varieties.  —  The  affections  to  which 
I  joints  are  liable  are  almost  all  due  to 


JOINTS.    SYNOVITIS.  SYMPTOMS. 


263 


inflammation  and  its  results.  Their 
character  varies  according  to  the  causes 
which  originate  them  and  the  extent  to 
which  the  disease  progresses.  If  the  in- 
flammatory action  is  confined  to  the  lin- 
ing membrane  of  the  joints,  then  it  is 
designated  as  a  synovitis.  If,  however,  it 
goes  farther,  and  involves  the  remaining 
structures  in  addition,  then  it  is  spoken 
of  as  an  arthritis.  If  pus  is  a  prominent 
symptom,  it  may  be  called  a  purulent 
synovitis  or  arthritis,  although  when  this 
occurs  it  is  more  apt  to  be  regarded  as  an 
arthritis.  Micro-organisms  play  an  im- 
portant part  at  times  in  joint-inflamma- 
tions. These  are  usually  of  the  ordinary 
pus-producing  kinds,  such  as  produce 
suppuration  in  ordinary  wounds,  or  sep- 
sis. When  this  is  the  case,  one  speaks  of 
a  septic  arthritis.  If  the  exact  source  of 
the  infection  is  known,  then  the  specific 
cause  of  the  affection  results  in  naming 
it  according  to  its  origin.  •  Thus  one 
speaks  of  rheumatic,  gouty  or  tubercular 
arthritis,  also  of  gonorrheal  or  syphilitic. 
Sometimes  a  special  name  is  given,  such 
as  osteoarthritis,  not  indicating  its  ori- 
gin, but  rather  the  parts  affected;  also 
Charcot's  disease  of  the  joints,  so  named 
after  him  who  described  it, 

Loose  bodies  in  joints  occur  as  the  re- 
sult of  injury  or  disease.  When  the  dis- 
ease affecting  a  joint  pursues  an  extreme 
course,  the  functions  of  the  joint  are  de- 
stroyed and  it  may  no  longer  bend. 
'I'll is  state  of  more  or  less  complete  fixa- 
tion is  called  ankylosis,  and,  after  the 
diseased  process  has  died  out  and  en- 
tirely ceased  to  act,  it  alone  remains  and 
may  be  the  cause  of  the  patient's  seek- 
ing the  surgeon  and  demanding  relief. 

Synovitis. 

Synovitis  is  the  name  given  to  a  sim- 
ple inflammation,  which  is  supposed  to 
be  limited  to  the  synovial  membrane.  It 
is  apt  to  be  incorrectly  applied,  at  times, 


on  account  of  other  structures  of  the 
joint  being  affected  at  the  same  time. 
The  term  simple  synovitis  is  of  consider- 
able service  to  designate  those  inflamma- 
tions which  cannot  be  traced  to  specific 
irritants,  such  as  gout  and  rheumatism, 
nor  to  disease  of  contiguous  structures, 
such  as  the  bones. 

Symptoms. — The  symptoms  are  those 
common  to  inflammations  in  general, 
such  as  pain,  heat,  redness,  and  swelling, 
with  impairment  of  function,  as  well  as 
others  due  to  the  peculiarities  of  the 
special  structure  or  part  involved. 
Acute  Synovitis. — In  acute  synovitis 

i  the  pain  may  vary  from  slight  to  ex- 
cessively severe.  The  rapidity  with 
which  the  effusion  may  occur  can  cause 
intense  pain  by  distension  of  the  joint- 
capsule.  The  joint  may  be  red  and  hot 
to  the  touch  and  very  tender.  The 
swelling  is  due  mainly  to  distension  of 
the  joint,  both  by  the  increase  in  size  of 
the  synovial  fringes  and  to  the  increased 
effusion.  Swelling  is  a  most  important 
symptom,  and  it  is  much  more  marked 
in  some  cases  than  in  others.  In  such 
joints,  as  the  knee,  that  are  not  deeply 
covered  by  soft  parts  the  swelling  is 
marked  and  peculiar  in  shape,  while  in 
those  which  are  not  so  superficial,  as  the 

j  shoulder  and  hip,  it  may  be  so  slight  as 
not  to  be  evident.  In  these  latter  joints 
there  may  be  a  slight  uniform  enlarge- 
ment which  it  would  be  difficult  to  say 
was  not  due  to  the  bruising  of  the  soft 
parts  in  case  the  affection  followed  an 
injury.  In  the  knee  and  ankle,  on  the 
contrary,  the  swelling  may  be  marked, 
and  follow  accurately  the  outlines  of  the 
joints.  It  is  influenced  in  its  shape  by 
the  overlying  structures.  Thus,  in  the 
knee-joint  the  swelling  of  the  synovial 
fringes  below  the  patella  causes  a  pro- 
trusion at  that  point,  which  is  more 

!  marked  on  each  side  of  the  tendo-patella?. 


2G± 


JOINTS.    SYNOVITIS.  ETIOLOGY. 


There  may  be  a  swelling  above  the  pa- 
tella or  on  each  side.  The  patella  is  like- 
wise lifted  np  away  from  the  femur  by 
the  effusion,  forming  the  so-called  float- 
ing patella;  or,  pushing  the  patella  down- 
ward, it  can  be  felt  to  strike  against  the 
condyles  beneath.  When  the  subfemoral 
bursa  communicates  with  the  joint,  the 
swelling  often  extends  quite  a  distance 
above  the  patella.  In  the  ankle-joint 
the  swelling  is  more  toward  the  sides, 
but  is  also  seen  in  front.  Behind,  it  is 
not  so  marked  except  on  each  side  of  the 
tendo  Achillis,  which,  however,  does  not 
play  so  prominent  a  part  in  the  symp- 
toms of  affections  of  this  joint  as  do  the 
patella  and  its  tendon  in  those  of  the 
knee.  In  the  elbow  the  tendon  of  the 
triceps  muscle  also  causes  the  swelling  to 
be  more  marked  on  each  side  than  in  the 
middle.  Impairment  of  function  is  usu- 
ally marked,  and  movements  are  very 
painful  in  the  acute  type  of  the  affection. 
Not  only  does  pain  interfere  with  the 
joint's  functions,  but  the  effusion  into 
and  distension  of  the  joint  prevents  it 
from  performing  them  by  rendering  it 
looser  and  less  secure;  so  that  weakness 
is  marked,  and,  even  if  pain  is  absent, 
the  joint  is  practically  useless. 

Subacute  Synovitis.  —  In  subacute 
synovitis  the  symptoms  may  be  less 
abrupt  in  their  onset  and  less  violent  in 
character.  An  acute  attack  may  be  slow 
in  subsiding  or  the  affection  may  be  mild 
from  the  start.  The  heat,  pain,  and  red- 
ness are  not  so  marked  as  in  the  acute 
type,  and  the  antiphlogistic  measures  of 
treatment  are  not  required  to  be  so  pro- 
nounced. 

Chronic  Synovitis. — In  chronic  syn- 
ovitis the  symptoms  are  characterized  by 
their  persistence.  The  acute  pain  gives 
way  to  a  dull  persistent  pain,  aggravated 
by  use  of  the  joint  to  such  an  extent  as 
to  forbid  it  entirely.    The  redness  may 


[  disappear,  the  heat  may  be  slightly  or 
not  at  all  above  that  of  the  opposite  side, 

!  but  the  swelling  usually  remains  and 
forms  a  most  prominent  symptom.  The 
swelling  of  the  membranes  of  the  joint 

I  may  overshadow  the  effusion,  and  then 
the  joint  has  a  boggy  or  doughy  feel, 

j  which  is  highly  characteristic.  The 
swelling  may  be  very  great,  due  to  the 
large  amount  of  effusion.  Effusion  of 
lymph  is  most  apt  to  occur  in  the  violent 
inflammations  of  acute  attacks.  Pus 
does  not  often  occur  in  cases  of  simple 
synovitis,  because  infection  is  lacking. 
Should  this,  however,  from  any  cause 
take  place,  then  it  forms  quickly  enough. 
The  existence  of  chronic  synovitis  im- 
plies disuse  of  the  member  affected  for 
a  considerable  time.  Trophic  changes 
therefore  occur  which  produce  a  marked 
condition.  The  muscles  above  and  be- 
low the  joint  atrophy,  while  the  joint 
remains  swelled,  and  each  tends  to  ag- 
gravate the  appearance  of  the  other;  so 
that  together  they  form  a  picture  of 
helplessness  which  is  amply  borne  out  by 
the  total  inability  of  the  patient  to  use 
the  joint.  If  a  joint  of  the  lower  ex- 
tremity is  affected,  the  patient  is  com- 
pelled either  to  refrain  from  walking  or 
hobbles  about  only  with  the  greatest  dif- 
ficulty, while  if  the  upper  extremity  is 

!  involved  the  arm  is  usually  carried  in  a 
sling. 

Peculiar  form  of  chronic  synovitis  of 
the  sheath  common  to  the  short  extensor 
and  long  abductor  of  the  thumb  observed 
in  two  cases.  Kochcr's  fibrous  stenosing 
synovitis, — more  or  less  pain  in  sheath, 
irradiating  throughout  forearm.  F.  de 
Quervain  (La  Semaine  Med.,  July  10, 
'95). 

Etiology. — The  principal  cause  of  sim- 
ple synovitis  is  injury.    The  joint  may 
have  been  knocked,  bruised,  or  strained. 
Exposure  to  cold  and  wet  may  be  fol- 
,  lowed  by  a  simple  inflammation  of  a 


JOINTS.  SYNOVITIS. 

joint,  with  no  other  evidences  of  rheu- 
matic or  other  constitutional  affection. 
Sometimes  the  disease  seems  to  appear 
without  immediate  cause,  but  in  these 
cases  the  affection  has  probably  been  the 
result  of  an  injury  so  slight  as  not  to 
have  attracted  the  attention  of  the  pa- 
tient at  the  time  or  else  have  been  since 
forgotten. 

Pathology. — The  affection  consists  of 
an  inflammation  of  the  synovial  mem- 
brane of  the  joint  with  an  outpouring  of 
synovia,  serum,  lymph,  or  pus  into  the 
joint-cavity. 

The  joint-surfaces  may  lose  to  some 
extent  their  smooth,  glistening  charac- 
ter, the  synovial  fringes  become  injected 
and  begin  to  proliferate  and  tend  to  en- 
croach on  the  interior  of  the  joint  and 
the  surrounding  cartilage.  The  natural 
secretion  of  the  joint  may  become  in- 
creased, it  may  contain  lymph  or  even 
pus.  In  a  quickly-occurring  synovitis 
the  secretion  may  be  thinner  than  nor- 
mal, owing  to  the  sudden  outpouring  of 
serum.  Not  infrequently  the  injury 
which  has  produced  the  synovitis  may 
likewise  have  caused  some  bleeding  into 
the  joint,  in  which  case  the  contained 
fluid  will  be  blood-stained  or  consist  even 
of  blood-clots. 

Treatment.  —  The  treatment  of  syn- 
ovitis varies  with  its  acuteness.  In  a 
sharp  attack  constitutional  disturbance 
may  be  marked,  the  pain  is  severe  and 
fever  high,  the  patient  is  tortured  by 
suffering  and  deprived  of  sleep.  The 
usual  antiphlogistic  treatment  is  here  of 
service;  a  free  saline  purge  is  of  service 
aided  by  acetanilid  or  phenacetin.  To 
produce  sleep  sul phonal  or  trional  may 
suffice,  or  if  the  pain  is  more  severe 
Dover's  powder  or  other  opiate  may  be 
given  in  sufficient  quantities  to  procure 
rest. 

Local    treatment    is    all  important. 


TREATMENT.  265 

Complete  rest  of  the  part  is  essential. 
If  the  knee  is  affected  sand-bags  may  be 
placed  on  each  side  or  a  pasteboard  splint 
on  the  back  of  the  leg  fastened  by  ad- 
hesive straps  above  and  below  the  joint, 
leaving  the  latter  exposed  for  treatment. 
A  cradle  should  be  used  to  prevent  the 
bed-clothes  from  touching  the  part. 

Literature  of  '96-'97-'98. 

In  the  treatment  of  acute  synovitis  by 
adhesive  plaster,  the  following  is  usual 
plan  of  procedure  in  acute  synovitis  of 
the  knee  (which  is  the  joint  most  com- 
monly involved)  :  The  limb  being  in  the 
position  of  greatest  possible  extension,  a 
pad  of  cotton  wadding  or  absorbent  cot- 
ton is  carefully  and  smoothly  placed  back 
of  the  knee,  well  filling  the  popliteal 
space  and  covering  the  hamstring-ten- 
dons; next,  sheet  cotton  (cotton  batting) 
torn  or  cut  into  ordinary  bandage-width 
is  wrapped  around  the  limb  from  six  or 
eight  inches  below  to  the  same  distance 
above  the  patella;  then  strips  of  rubber 
adhesive  plaster,  one  inch  wide  and  long- 
enough  to  more  than  encircle  the  limb, 
are  applied  over  the  soft,  cotton  dressing 
as  follows:  Beginning  four  to  six  inches 
below  the  joint,  according  to  the  size  of 
the  limb,  the  leg  is  encircled  like  a  gar- 
ter with  a  strip  of  the  plaster,  which  is 
drawn  quite  snug  and  the  ends  stuck  to- 
gether; above  this,  and  overlapping  one- 
third,  a  second  strip  is  applied;  and  so 
on,  strip  next  to  strip,  each  overlapping 
the  one  before,  drawing  them  snug  and 
sticking  the  ends  together,  until  the  joint 
and  from  four  to  six  or  more  inches  of 
both  leg  and  thigh  are  incased  in  a  firm, 
adhesive  plaster  support.  Over  all  a  mus- 
lin bandage  is  applied. 

When  the  plaster  becomes  loose,  in  con- 
sequence of  the  subsidence  of  swelling,  it 
should  either  be  made  snug  again  by  ap- 
plying additional  strips,  or,  better  still, 
entirely  removed  and  a  new  dressing 
applied.  The  results  obtained  by  this 
method  are  remarkable.  Hoffmann  (St. 
Louis  Med.  and  Surg.  Jour.,  Feb..  '96). 

Bleeding  has  gone  somewhat  out  of 
fashion,  but  a  few  Swedish  leeches  or 


PATHOLOGY. 


266 


JOINTS.    SYNOVITIS.  TREATMENT. 


the  application  of  a  few  wet  cups  will 
give  quicker  results  than  almost  any 
other  means.  The  cases  in  which  one 
will  be  inclined  to  use  those  means  are, 
however,  few.  Ordinarily  an  ice-cap  may 
be  applied,  but  in  other  cases  hot  applica- 
tions, such  as  woolen  cloths  wrung  out 
of  hot  water,  or  hot-salt  bags,  or  a  hop 
poultice  made  by  heating  hops  in  a  pan, 
moistening  them  with  vinegar  and  in- 
closing them  in  a  bag,  or  even  the  use  of 
the  ordinary  rubber  hot-water  bottle. 

Personally  1  am  partial  to  the  use  of 
the  splint  and  ice-cap,  and  then  when 
the  pain  and  tenderness  have  somewhat 
subsided  light  massage  may  be  employed. 
Massage  is  not  used  to  anything  like  the 
extent  it  deserves.  Employed  daily  very 
lightly  at  first  and  afterward  more  firmly, 
I  am  convinced  of  its  great  efficacy. 

Obstinate  cases  of  subacute  and  chronic 
synovitis  I  am  convinced  are  best  treated 
by  absolute  rest,  as  far  as  any  use  of  the 
joint  is  concerned.  The  disease  is  often 
kept  alive  and  troublesome  because  the 
patient  persists  in  using  the  joint  to  the 
extent  that  the  pain  will  allow  him  to. 
Massage  is  not  incompatible  with  rest, 
but  violent  passive  motion  is.  Therefore 
the  joint  may  be  rubbed  to  keep  up  its 
circulation  and  nutrition,  but  not  irri- 
tated by  bending.  Hot-air  baths  are  like- 
wise of  the  greatest  service  to  remove 
stiffness. 

Six  cases  of  chronic  synovitis  treated 
and  cured  by  massage.  The  seances  were 
repeated  once  daily,  lasting  each  time 
from  fifteen  to  twenty-five  minutes. 
Greidenberg  (Sei-I-Kwai  Med.  Jour.,  Oct., 
'89). 

The  question  of  tapping  a  distended 
joint  to  remove  the  effusion  is  an  impor- 
tant one.  I  do  not  believe  it  correct  to 
say  thai  the  procedure  is  without  (lun- 
ger. On  the  contrary,  it  should  be  done 
in  the  most  careful  manner,  or  else  the 


joint  is  apt  to  be  infected  and  a  serous 
effusion  changed  to  a  purulent  one,  with 
a  possible  disorganization  of  the  joint. 
To  properly  tap  a  joint,  the  first  thing 
is  to  get  a  sharp  trocar  the  cannula  of 
which  is  so  closely  fitted  as  to  allow  it 
to  pass  through  a  piece  of  leather  with- 
out catching.  Very  few  trocars  stand 
this  test,  and  all  others  are  positively 
dangerous.  It  should  be  thoroughly  dis- 
infected— preferably  by  boiling.  The 
part  should  be  likewise  thoroughly 
cleansed  by  scrubbing  and  antiseptics, 
the  same  as  for  any  other  serious  sur- 
gical operation.  The  surgeon's  hands 
also  require  the  same  careful  treatment. 
After  tapping,  the  opening  should  pref- 
erably be  sealed  with  collodion  and  gauze 
or  cotton.  If  a  bandage  is  applied  with 
a  dressing,  the  greatest  care  should  be 
taken  that  it  be  so  large  and  so  firmly 
secured  that  by  no  possibility  can  it  be- 
come displaced  and  the  puncture  ex- 
posed. Tapping  done  in  this  manner  is 
of  great  service  and  not  accompanied  by 
much  risk, — personally  I  have  never  had 
the  slightest  bad  effects  from  it,  but 
make  it  a  positive  rule  to  observe  the 
greatest  precautions  against  introducing 
infection. 

Stiffness  following  synovitis,  in  which 
pain  is  not  marked,  may  be  treated  by 
persistent,  but  not  violent,  passive  mo- 
tion and  massage.  If  this  is  not  success- 
ful, then  a  free  movement  of  the  joint 
under  an  anaesthetic  may  be  tried,  fol- 
lowed for  a  short  time  by  complete  rest 
and  the  ice-cap  until  reaction  is  past, 
when  passive  movements  and  massage, 
the  use  of  the  hot-air  bath,  the  applica- 
tion, perhaps,  of  iodine  to  the  joint  or 
compression  by  a  rubber  bandage  may  be 
tried.  Chronic  joint-affections  will  tax 
the  skill  of  the  most  experienced,  and 
the  surgeon  must  call  on  his  ingenuity 
to  devise  means  to  achieve  success. 


JOINTS.    ARTHRITIS.    SYMPTOMS.  267 


Arthritis. 

Arthritis  is  an  inflammation  of  the 
entire  joint,  instead  of  only  its  synovial  i 
membrane  as  in  synovitis.  Clinically  the 
difference  is  mainly  one  of  degree.  An 
inflammation  that  begins  in  the  synovial  \ 
membrane  may  involve  the  capsule,  the 
cartilages,  and  eventually  the  bones.  It 
is  a  more  serious  affection,  more  severe 
in  its  symptoms,  more  exacting  in  its 
treatment,  and  more  serious  in  its  prog- 
nosis. It  may  be  started  by  an  injury, 
by  exposure,  by  infection  either  direct 
or  by  extension  from  neighboring  dis- 
eased structures,  or  by  a  constitutional 
cause. 

Symptoms. — In  arthritis  the  symptoms 
peculiar  to  synovitis  are  more  marked; 
the  fever  is  high  if  the  disease  is  acute; 
the  constitutional  disturbance  is  severe; 
the  swelling  is  marked;  oedema  may  be 
present;  the  joint  tender,  particularly  on 
its  surface,  as  well  as  deeper  in;   it  is 
flexed  and  rigid;  the  atrophy  of  the  mus- 
cles is  rapid;  if  it  is  moved  grating  may 
be  heard,  owing  to  destruction  of  the 
cartilage;  and,  as  the  disease  advances, 
sinuses  may  form,  bone  may  exfoliate, 
and  even  dislocations  occur,  with  total 
disorganization  of  the  joint.  Sometimes 
the  disease  necessitates  amputation  or 
causes  death.    Often  its  course  is  very 
rapid.    Infants  are  particularly  liable  to 
a  form  caused  by  extension  of  inflamma- 
tion from  the  adjacent  epiphysis,  and  it 
is  productive  of  the  most  serious  results. 
Seventy-one  cases  of  acute  arthritis  in 
infants,  45  per  cent,  of  which  died.  In 
52  cases  but  one  joint  was  affected, — ■ 
mortality,  34  per  cent.   In  15  cases  more 
than  one  joint  was  involved, — mortality, 
75   per   cent.     Disease   regarded    as  an 
osteomyelitis,  due  to  the  staphylococcus 
pyogenes  aureus,  and  most  frequent  dur- 
ing  the  first  year  of  life.  Dubreuilh 
(Revue  d'Orth.,  Sept.,  '90). 

Auscultation  in  joint-disease  quite  as 
useful  as  in  affections  of  the  lungs.  Nor- 


mal, very  little  derangement  within  the 
joint,  giving  no  pain,  leads  to  abnormal 
sounds,  increasing  in  degree  as  the  im- 
pediment is  intensified.  Five  joint- 
sounds:  (1)  simple,  dry  friction-sound; 
(2)  dry  grating  sound;  (3)  coarse  grat- 
ing sound;  (4)  moist  crepitant  sound, 
and  (5)  coarse,  crepitant  sound.  Sir 
Benjamin  Ward  Richardson  (Asclepiad, 
3d  Q.,  '94-'95). 

Literature  of  '96-'97-'98. 

Reflex  muscular  spasm  regarded  as  the 
one  most  important  sign  in  chronic  joint 
disease.  By  it  is  meant  a  tonic  spasm  or 
contraction  of  all  or  some  of  the  muscles 
in  relation  to  a  diseased  joint.  It  is  pres- 
ent only  in  those  muscles  which  act  upon 
the  diseased  articulation;  it  is  almost 
without  exception  the  expression  of  bone- 
inflammation;  it  is  the  first  sign  to  ap- 
pear, and  it  persists  till  healing  has  taken 
place.  Le  Roy  W.  Hubbard  (  Amer. 
Medico-Surg.  Bull.,  Jan.  11,  '96). 

In  children  a  chronic  progressive  en- 
largement of  the  joints  associated  with 
general  enlargement  of  glands  and  en- 
largement of  the  spleen,  usually  begins 
before  the  second  dentition,  the  majority 
of  the  patients  being  girls. 

The  onset  is  usually  insidious,  but  oc- 
casionally is  acute,  with  rigors.  The 
change  in  the  joints  suggests  a  general 
thickening  of  the  tissues  around  the  joint 
rather  than  a  bony  enlargement,  and 
there  is  a  striking  absence  of  osteophytic 
outgrowths  even  when  the  disease  has 
persisted  for  years.  Redness  and  tender- 
ness are  present  only  in  the  more  acute 
cases :  but  there  is,  as  a  rule,  marked 
limitation  of  movement.  The  joints  first 
affected  are  usually  the  knees,  wrists, 
and  those  of  the  cervical  spine.  The 
sterno  clavicular  joint  was  affected  in 
two  out  of  twelve  cases,  the  temporo- 
maxillary  in  three.  There  is  no  tendency 
to  suppuration  or  bony  ankylosis.  Wast- 
ing of  the  muscles  which  move  the 
affected  joints  is  a  striking  feature  of  the 
disease. 

The  glandular  enlargement  is  general, 
but  affects  primarily  and  chiefly  the 
glands  related  to  the  affected  joints. 
The  glands  are  discrete,  firm,  painless, 
and  show  no  tendency  to  break  down. 


2G8 


JOINTS.    ARTHRITIS.  TREATMENT. 


The  enlargement  is,  to  some  extent,  pro- 
portionate to  the  severity  of  the  disease, 
and  tends  to  diminish  when  the  condition 
of  the  joints  improves,  and  vice  versa. 
The  splenic  enlargement  is  observed  in  a 
large  proportion  of  the  cases.  It  bears 
some  relation  to  the  degree  of  enlarge- 
ment of  the  glands. 

Valvular   disease    is    not    met  with. 
Anaemia  of  moderate  or  slight  degree 
usually    observed.     In    some  instances 
there  is  slight  continued  pyrexia.  Sweat- 
ing is  often  profuse  and  bears  no  relation 
to  the  temperature.    Arrest  of  bodily  de- 
velopment is  usually  present,  but  the 
mental  powers  are  in  no  way  impaired. 
The  progress  of  the  disease  is  slow,  and 
in  time  it  tends  to  become  stationary. 
Death,  when  it  occurs,  results  from  com- 
plications.    G.   F.    Still  (Medico-Chir. 
Trans.,  vol.  lxxx,  p.  47,  .'97). 
Treatment. — The  treatment  of  arthri- 
tis in  its  mild  form  is  practically  that  of 
synovitis,  which  has  already  been  de- 
tailed at  length.    It  is,  in  the  highest 
degree,  desirable  that  the  serious  char- 
acter of  the  affection  be  recognized  as 
soon  as  possible,  in  order  that  more  rigid 
precautions  may  be  taken  than  would  be 
considered  necessary  in  synovitis.    It  is 
more  justifiable  to  resort  to  severe  meas- 
ures.   The  consequences  of  an  arthritis 
are  almost  sure  to  be  some  limitation  of 
the  usefulness  of  the  joint;  not  seldom 
does  total  stiffness  ensue  or  the  suppura- 
tion may  be  so  marked  as  to  demand  re- 
section or  amputation  to  save  life.   If  the 
disease  is  acute  absolute  rest  in  bed  with 
the  limb  on  a  posterior  splint  (if  knee  is 
affected)  is  to  be  enforced,  with  the  ap- 
plication of  leeches,  wet  cups,  or  ice. 
Sometimes  it  is  desirable  to  apply  ad- 
hesive-plaster extension  with  weights. 
The  amount  of  weights  used  is  to  be 
gauged  by  the  patient's  feelings.    In  the 
hip-joint  particularly  extension  is  neces- 
sary.  In  the  ankle  and  shoulder  plaster- 
of-Paris  fixation-splints  are  of  service,  j 
because  in  those  joints  movements  are 
most  apt  to  be  marked. 


In  addition  to  rest,  the  employment  of 
prolonged,  properly  graduated,  dry  re- 
frigeration of  the  joints  advised.  Gerster 
(Annals  of  Surg.,  Apr.,  '88). 

Acute  inflammations  are  rapidly  cured 
by  the  salicylates,  with  aconite  or  digi- 
talis for  the  liquefacient  and  depressant 
indications.  Illingworth  (Collaborator 
of  the  Annual,  '90). 

Literature  of  '96-'97-'98. 

In  treatment  of  injured  and  diseased 
joints  massage,  with  passive  motion,  in- 
dicated. Personal  belief  in  commencing 
the  massage  immediately.  The  massage, 
beginning  at  the  periphery  and  then  ex- 
tending to  the  joint,  is  not  painful,  and 
acts  to  remove  the  extra vasated  fluid 
which  is  the  cause  of  the  trouble.  After 
the  massage  the  joint  is  placed  in  a  com- 
pressive cotton  dressing,  fixed  upon  a 
splint  and  placed  in  an  elevated  position. 
The  massage  is  continued  in  daily  -it- 
tings.  After  three  or  four  days  the  splint 
is  removed,  and  after  the  disappearance 
of  the  swelling  passive  motion  is  com- 
menced, while  the  use  of  the  joint  is  fully 
restored  at  the  end  of  fourteen  days.  The 
time  at  which  passive  motion  should  be 
commenced  is  of  great  interest.  It  has 
for  its  purpose  the  prevention  of  atrophy 
in  the  soft  structures  of  the  joint  and  in 
the  group  of  muscles  which  moves  the 
limb. 

In  the  elbow  passive  motion  should  be 
commenced  on  the  third  or  fourth  day. 
In  giving  the  passive  motions  the  Swed- 
ish method  is  employed,  where  the  patient 
offers  a  slight  muscular  resistance  to  the 
motion.  Gonorrhoeal  arthritis  and  those 
forms  of  arthritis  which  occasionally  ap- 
pear in  typhoid,  measles,  scarlet  fever, 
small  pox,  dysentery,  and  diphtheria,  ad- 
vised to  be  let  alone.  Massage  especially 
warned  against  in  gonorrhoea]  arthritis. 
Massage  advocated  in  cases  of  arthritis 
due  to  fungoid  tubercular  granulations. 
Klemm  (St.  Petersburger  med.  Woch., 
No.  28,  '97). 

Cartilage  in  a  healthy  state  is  not  sen- 
sitive, but  when  a  joint  becomes  inflamed 
any  pressure  of  the  joint-surfaces  to- 
gether is  productive  of  great  pain  and 


JOINTS.    ARTHRITIS.  TREATMENT. 


269 


increases  muscular  spasm.  Should  the 
inflammation  continue  increasing,  the 
joint  should  be  tapped  as  described  un- 
der the  treatment  of  synovitis;  instead, 
however,  of  merely  allowing  the  liquid 
joint-contents  to  escape,  the  whole  joint 
should  be  washed  out.  For  this  purpose 
sterilized  salt  solution,  a  saturated  solu- 
tion of  boric  acid  which  has  been  boiled, 
or  a  weak  bichloride-of-mercury  solution,  I 
1  to  3000  or  1  to  5000,  may  be  used. 

In  eases  of  knee-joint  irrigation  we  do 
not  hope  to  do  more  than  to  greatly  in- 
hibit the  activity  of  the  micro-organisms 
— to  assist  the  tissues  to  destroy  the 
micro-organisms".  That  solutions  of  bi- 
chloride of  mercury  are  more  efficacious 
than  salt  solutions  in  destroying  and  in- 
hibiting pyogenic  organisms  outside  of 
the  body  we  have  sufficient  proof.  Hal- 
sted  (Johns  Hopkins  Hosp.  Bull.,  Dec, 
'95). 

If  the  inflammation  increases  and  pus 
forms,  then  the  joint  will  have  to  be 
drained.  Drainage  of  the  various  joints 
is  not  apt  to  be  a  very  satisfactory  pro- 
cedure. This  is  on  account  of  there 
being  no  empty  spaces  for  the  drainage- 
tube  to  lie  in.  The  bones  touch  each 
other  and  the  interspaces  are  filled  with 
the  synovial  fringes,  while  all  are  closely 
embraced  by  the  capsular  ligament.  The 
knee-joint  is  the  one  most  commonly 
treated  by  drainage.  One  of  the  best 
methods  is  to  pass  a  tube  into  the  joint 
just  below  the  patella  and  to  the  inner 
side  of  the  median  line.  It  is  then  car- 
ried between  the  condyles  and  made  to 
emerge  posteriorly  to  the  outer  side  of 
the  popliteal  vessels.  Another  way  is  to 
insert  one  on  each  side  of  the  patella 
and  another  well  back  in  the  joint  from 
side  to  side.  The  joint,  however,  is  such 
an  intricate  one  that  good  drainage  is 
very  difficult,  and  if  the  disease  increases 
something  further  may  have  to  be  done. 
The  choice  will  lay  between  amputation 
or  resection  and  some  form  of  arthrot- 


omy.  The  recuperative  powers  of  child- 
hood are  so  great  that  conservatism  is 
far  more  judicious  than  is  the  case  in 
youths  and  adults.  In  young  children 
partial  procedures  are  often  preferable 
to  more  radical  ones.  Eesections  in 
them  give  extremely  bad  results  on  ac- 
count of  the  interference  caused  with  the 
growth  of  the  limb.  The  disability  and 
deformity  which  at  the  time  of  the  op- 
eration may  have  been  comparatively 
slight  can  become  so  severe  as  to  make  a 
subsequent  amputation  desirable.  Am- 
putations are  resorted  to  only  as  a  means 
of  saving  life  in  children,  but  in  adults 
the  probability  of  a  good  result  after 
very  extensive  bony  disease  is  so  slight 
that  in  them  amputation  is  justifiable 
where  in  a  child  resection  would  suffice. 
In  adults,  also,  resection  of  a  joint  is  re- 
sorted to  earlier  than  in  children.  If  a 
marked  purulent  arthritis  once  becomes 
established  in  an  adult  resection  is  often 
demanded,  and  it  is  not  advisable  to 
defer  operating  until  extensive  disease  of 
the  bones  is  present.  After  pus  once 
forms  in  the  joint  of  an  adult  the  joint 
is  very  apt  to  remain  stiff  even  if  cure 
occurs,  whereas  the  result  after  a  resec- 
tion is  no  worse  and  the  course  of  the 
disease  is  much  shortened.  One  does  not 
have  to  fear  subsequent  deformity  due 
to  the  disparity  in  growth  of  the  two 
limbs.  In  very  young  children  formal 
resections  may  give  way  to  atypical  op- 
erations, in  which  the  disease  foci  are 
gouged  away  and  even  some  cavities  de- 
liberately cleansed  out  and  packed  with 
gauge  and  left  to  granulate.  Even  these 
partial  operations  should  not  be  under- 
taken until  the  disease  is  marked. 

Twenty-eight  cases  of  operations  upon 
joints  in  which  the  joint  was  opened,  and 
in  but  one  was  subsequent  amputation 
found  necessary.  Bruce  Clark  (Illus. 
Med.  News,  Dec.  14.  '80). 

Astragalus  which  had  been  removed 


270 


JOINTS.    ARTHRITIS.  TREATMENT. 


during  an  operation  for  arthritis  of  the 
ankle  and  placed  in  a  0.6-per-cent.  luke- 
warm chloride-of- sodium  solution  success- 
fully replaced.  Paulsen  (Dublin  Jour,  of 
Med.  Sci.,  Feb.,  '90). 

Drilling  into  the  bones  in  the  neighbor- 
hood of  inflamed  joints  and  injecting 
carbolic  acid,  1  in  40,  recommended,  thus 
relieving  pain  and  hastening  recovery. 
N.  Smith  (Brit.  Med.  Jour.,  Feb.  22,  "90). 

The  failure  of  general  health  is  the 
best  indication  for  operative  procedures. 
In  children  up  to  the  age  of  about  five 
years  even  free  suppuration  of  a  joint 
may  often  be  cured  without  severe  opera- 
tions. A  great  deal  depends  on  the 
mechanical  ability  of  the  surgeon  to 
handle  these  cases  conservatively. 

Arthrectomy,  or  erosion,  is  the  scrap- 
ing, or  curetting,  of  the  joint  with  the 
removal  of  the  synovial  membranes  as 
much  as  possible.  Its  results  have  not 
been  so  brilliant  as  was  anticipated.  The 
procedure  will  probably  be  followed  by 
stiffness,  and  the  likelihood  of  cure  is 
not  so  great  as  if  a  formal  resection  is 
done.  It  is  most  applicable  in  children 
of  an  age  unsuitable  for  resection.  In 
them  accompanied  by  a  free  use  of  the 
curette  for  the  removal  of  disease  foci 
in  the  bones  it  is  the  operation  of  choice. 
As  one  approaches  adult  age  so  does  its 
desirability  lessen. 

Treatment  of  Chronic  Cases. — Ar- 
thritis not  infrequently  pursues  an  ex- 
tremely chronic  course.  Its  treatment  is 
to  be  varied  according  to  the  diathesis 
present.  Thus  syphilis  or  rheumatism 
or  other  constitutional  affection  should 
receive  the  constitutional  remedies  ap- 
propriate to  them  in  addition  to  the  local 
treatment.  Many  arthritic  cases  are  kept 
in  a  chronic  condition  by  the  inability  or 
indisposition  of  the  patient  to  keep  the 
joint  sufficiently  long  at  rest  for  a  cure 
to  be  effected.  I  have  frequently  seen 
joints  improve  after  other  methods  had 


been  tried  when  absolute  rest  in  bed  was 
enjoined.  This  rest  should  be  insisted 
on  until  all  evidences  of  activity  of  the 
disease  have  ceased.  The  joints  of  the 
lower  extremities  are  the  ones  most  often 
affected,  but  those  of  the  upper  are  like- 
wise attacked.  When  the  wrist  is  in- 
volved the  hand  and  forearm  up  to  the 
elbow  may  be  enveloped  in  a  plaster-of- 
Paris  or  preferably  a  silicate-of-soda 
bandage.  Another  convenient  way  of 
fixing  the  wrist  is  by  means  of  leather. 
A  piece  of  harness  or  not  too  heavy  sole- 
leather  is  obtained,  and  two  pieces  cut 
of  a  size  suitable  to  reach  from  near  the 
elbow  to  the  metacarpophalangeal  joint 
and  each  half  way  around  the  arm.  They 
are  then  to  be  soaked  in  warm — not  hot 
— water  and  applied  to  the  arm;  with  a 
penknife  a  space  is  cut  for  the  thumb 
and  the  splints  shaped  to  fit  the  hand 
and  forearm.  The  edges  may  be  shaved 
thin  so  as  to  allow  of  overlapping.  With 
a  bandage  the  two  pieces  of  leather  are 
fastened  firmly  on  and  allowed  to  remain 
until  the  next  day.  They  will  then  be 
found  to  be  hard  when  they  can  be  re- 
moved, lined  by  pasting  chamois-skin  on 
the  inside  and  the  two  splints  fitted 
either  with  straps  or  eyelit  holes  for 
lacing.  Over  the  affected  joint  a  piece 
of  lint  spread  with  belladonna  and  mer- 
cury or  ichthyol  ointment  may  be  spread 
or  it  may  be  painted  with  iodine  or 
treated  in  any  way  desired.  The  use 
of  the  local  hot-air  baths  is  very  desir- 
able in  arthritis  arising  from  traumatic 
or  rheumatic  causes,  but  not  in  tuber- 
cular ones.  This  is  likewise  true  of  elec- 
tricity and  massage.  These  hot-air  baths 
should  be  carefully  watched  to  see  if 
their  effect  is  suitable  to  the  particular 
case,  for  not  infrequently  they  aggravate 
instead  of  alleviate  the  trouble. 

For  stiff  and  sprained  joints,  the  limb 
with  the  affected  joint   i^  placed  in  an 


JOINTS.    ARTHRITIS.  TREATMENT. 


271 


appropriate  box  and  the  temperature 
gradually  and  yet  rapidly  raised  from 
240°  F.  to  280°  F.,  and  even,  in  some 
cases,  to  300°  F.  This  temperature  is 
maintained  from  half  an  hour  to  an  hour. 
The  treatment  is  not  uncomfortable,  al- 
though the  skin  becomes  very  red  and 
moist.  The  results  are  very  satisfactory, 
some  of  them  being  almost  marvelous. 
Alfred  Willett  (Clin.  Jour.,  May  30,  '94). 

Literature  of  '96-'97-'98. 

Hot  air  is  almost  always  followed  by 
good  results;  but  in  one  case  there  was 
much  inflammation  about  the  joints  and 
success  did  not  attend  the  treatment. 
Alice  M.  Seabrooke  (Phila.  Polyclinic, 
July  30,  '98). 

Very  good  results  following  applica- 
tions of  hot  air  for  about  an  hour,  the 
temperature  being  brought  up  to  about 
250°,  and  in  some  cases  to  300°.  The 
structures  about  the  joints  are  much  soft- 
ened by  such  treatment,  and  yield  to 
forced  stretching.  J.  T.  Rugh  (Phila. 
Polyclinic,  July  30,  '98). 

When  any  one  of  the  three  large  joints 
of  the  upper  extremity  is  affected  the 
hand  should  be  carried  in  a  sling. 

When  the  elbow  or  shoulder  is  to  be 
treated  the  silicate  of  soda  probably 
makes  the  best  splint-material.  It  would 
be  far  more  popular  than  it  is  if  the 
method  of  its  use  were  better  understood. 
The  secret  of  success  is  in  first  having 
the  bandages  thoroughly  impregnated 
with  the  silicate,  and,  secondly,  in  not 
applying  too  much  silicate  while  making 
the  splint. 

If  gauze  or  scrime  or  crinoline  is  used, 
then  it  is  easy  enough  to  have  it  thor- 
oughly soaked  with  silicate,  but  with  cot- 
ton bandages  a  certain  amount  of  silicate 
should  lie  placed  in  a  basin  and  the  band- 
age allowed  to  pass  through  it  as  it  is 
wound  by  hand.  A  convenient  machine 
for  the  preparation  of  these  bandages  is 
one  1  have  been  using  for  years.  It  con- 
sists of  n  V^-shaped  box  into  which  the 
silicate  is  poured.    The  bandage  goes 


over  the  edge  of  the  box  down  under  a 
rod  at  the  bottom  and  up  to  be  wound 
around  a  small  handle,  or  winch.  In 
applying  these  bandages  the  part  is  first 
covered  in  the  same  manner  as  for 
plaster-of-Paris.  All  surplus  silicate  is 
squeezed  from  a  bandage,  and  it  is  then 
applied.  After  a  couple  of  layers,  strips 
of  tin  are  laid  on  and  covered  by  a  couple 
more  layers  of  bandage.  These  tin  strips 
should  always  be  used  in  dressings  of 
any  size,  as  they  prevent  the  bandage's 
becoming  wrinkled,  and  keeps  it  in  shape 
until  properly  hardened,  and  also  adds 
somewhat  to  the  strength  of  the  appa- 
ratus. Additional  silicate  is  not  to  be 
smeared  on  over  the  various  layers  of 
bandage.  The  hand  should  be  moist- 
ened with  warm  water  and  the  bandage 
smoothed  therewith.  Made  in  this  man- 
ner, the  bandage  will  take  about  twenty- 
four  hours  to  dry,  and  will  get  as  hard  as 
a  stone  and  yet  be  extremely  light. 

It  may  be  made  removable  by  cutting 
down  with  a  knife  and  inserting  hooks 
or  eyelets.  If  hooks  are  desired,  the 
large  size  may  be  bought  at  any  dry- 
goods-store  and  these  sewed  to  the  folded 
edge  of  a  strip  of  unbleached  muslin. 
This  is  then  pasted  along  the  cut  edges 
of  the  bandage  with  additional  silicate 
and  left  for  another  twenty-four  hours 
to  dry.  The  bandage  if  applied  for  dis- 
ease of  the  elbow  should  be  carried  well 
up  toward  the  shoulder  and  down  toward 
the  wrist.  If  this  is  not  done  too  much 
motion  is  allowed  at  the  joint.  When 
the  shoulder  is  affected  the  arm  is  to 
be  confined  by  the  dressing  to  the  body 
to  prevent  its  swinging.  In  the  treat- 
ment of  chronic  joint  diseases  ortho- 
paedic apparatus  can  often  be  used  to 
advantage.  Thus  in  disease  of  the  el- 
bow-joint a  useful  form  is  composed  of 
two  side-irons  with  a  joint  opposite  the 
elbow,  which  is  capable  of  being  so  regu- 


272 


JOINTS.    RHEUMATIC  ARTHRITIS. 


lated  as  to  allow  a  little  or  no  motion  as 
is  desired.  The  two  side-irons  are  fast- 
ened to  the  arm  by  two  leather  sockets, 
one  lacing  around  the  arm  above  the 
elbow  and  the  other  below  the  elbow. 

Affections  of  the  hip- joint  are  usually 
treated  by  adhesive-plaster  extension, 
from  five  to  fifteen  pounds  being  used; 
the  limb  is  steadied  either  by  sand-bags 
on  each  side  or  by  means  of  a  long,  lat- 
eral splint. 

In  walking  cases  some  form  of  the  old 
Davis  or  Taylor  traction  splint  may  be 
used.  The  same  object  is  accomplished 
by  the  patient's  wearing  a  high  shoe  on 
the  healthy  limb  and  using  crutches. 
The  affected  limb  is  allowed  to  hang. 
To  steady  it  a  plaster-of-Paris  or  silicate- 
of-soda  or  other  dressing  is  applied 
around  the  pelvis  and  thigh,  down  to 
the  knee.  The  long  posterior  splint  of 
Thomas  is  also  of  service.  For  the  knee 
one  may  use  an  elastic  knee-cap  or  a 
light  plaster-of-Paris  splint,  or  one  made 
of  leather,  or  silicate-of-soda  or  even 
pasteboard  is  suitable.  Of  whatever  ma- 
terial the  splint  is  made,  it  should  go 
high  up  toward  the  hip  and  low  down 
toward  the  ankle,  otherwise  too  much 
motion  will  be  allowed.  Thomas  has 
also  devised  a  serviceable  apparatus  to  be 
used  in  these  cases.  It  is  composed  of 
two  side-irons  in  the  form  of  the  letter 
U.  The  two  upper  ends  are  joined  by  a 
padded  iron  ring  and  the  opposite  ex- 
tremity projects  beyond  the  foot.  The 
patient  puts  the  leg  through  the  ring 
and  practically  sits  down  on  it,  allowing 
the  leg  to  hang  between  the  side-irons. 
A  bandage  confines  the  apparatus  to  the 
limb.  Other  forms  of  apparatus  are  also 
of  service.  Thus,  one  can  be  made  with 
two  side-irons  which  are  jointed  opposite 
the  knee-joint.  At  least  one  of  these 
side-irons  goes  down  to  the  foot  and  is 
fastened  to  a  steel  sole-plate.    If  this  is 


not  done,  it  will  be  found  almost  impos- 
sible to  keep  the  apparatus  from  sliding 
down.  The  amount  of  motion  to  be 
allowed  is  regulated  by  altering  certain 
stops  at  the  knee-joint.  Many  of  these 
knee  cases  can  be  allowed  a  certain 
amount  of  motion  with  benefit,  because 
it  is  only  when  the  motion  is  excessive 
or  takes  place  in  some  unusual  direction 
— as  twisting — that  it  is  harmful. 

For  the  ankle,  silicate-of-soda,  plaster- 
of-Paris,  or  leather  supports  are  needed. 
In  light  cases  the  elastic-webbing  band- 

j  age  or  Martin's  rubber  bandage  gives 
considerable  support.  If  it  is  desired  to 
keep  the  joint  quiet,  then  the  dressing 
should  extend  well  out  toward  the  toes 
and  well  up  toward  the  knee.  For  more 
permanent  use  a  steel  sole-plate  may  be 
inserted  in  the  shoe,  and  from  it  two 
side-irons  go  up  the  leg.  There  need  be 
no  ankle-joint,  as  the  patient  can  walk 
quite  well,  even  with  the  ankle  stiff.  An 
apparatus  can  be  constructed  on  some- 
what similar  lines  to  go  inside  the  shoe, 
and  thus  can  be  worn  with  different 
shoes. 

Rheumatic  Arthritis. 
Rheumatic  affections  of  the  joints  do, 
at  times,  claim  the  attention  of  surgeons. 

j  Rheumatism  in  an  acute  form  comes 
under  the  care  of  the  physician,  but  not 
seldom  it  assumes  a  chronic  form  and 
becomes  localized  in  a  joint  and  produces 
such  disability  as  to  require  special  local 
treatment,  and  then  the  surgeon  is 
called  upon.  It  is  a  strange  fact,  al- 
though one  perfectly  well  known,  that 
an  injured  part  is  more  liable  to  become 

I  affected  with  rheumatism  than  one  pre- 
viously healthy.  Patients  who  have  suf- 
fered comparatively  little,  except  slight 

[  pains  in  various  parts  of  the  body.  may. 
after  the  reception  of  an  injury,  have  a 
distinct  rheumatic  inflammation,  in  a 
subacute  or  chronic  form,  affecting  the 


JOINTS.    RHEUMATIC  ARTHRITIS.    SYMPTOMS.  TREATMENT. 


273 


injured  part.  Any  physician  who  sees 
general  injuries  or  affections  of  the 
joints  is  certain  to  be  called  upon  to  treat 
cases  in  which  the  rheumatic  element 
plays  a  more  or  less  conspicuous  role. 
The  disease  in  an  early  stage  may  be 
only  a  synovitis,  with  serous  or  sero- 
fibrinous effusion  into  the  joint;  if,  how- 
ever, the  attack  is  exceptionally  severe, 
especially  in  duration,  the  whole  articu- 
lation becomes  involved.  The  sero- 
fibrinous effusion  may  be  abundant  and 
not  confined  to  the  joint,  but  involve  the 
capsule,  ligaments,  and  periosteum,  and 
even  extend  some  distance  into  the  sur- 
rounding structures.  The  cartilage  also 
suffers,  and  it  becomes  roughened  and 
may  even  be  worn  off,  leaving,  in  places, 
the  bone  exposed.  The  effusion  may  be 
of  a  plastic  character  that  will  bind  and 
mat  the  various  structures  of  the  joint 
and  its  neighborhood  together,  thus  pro- 
ducing a  fibrous  ankylosis.  Calcareous 
salts  may  be  deposited  in  this  exudate, 
producing  an  exostosis,  which  causes  a 
bony  ankylosis.  The  periosteum  engages 
actively  in  this  process.  It  is  probable 
that  many  cases  of  arthritis  which  are 
regarded  as  being  purely  of  a  traumatic 
character  owe  their  obstinate  course  to 
a  rheumatic  taint. 

In  the  majority  of  cases,  loose  bodies 
of  mixed  cartilaginous  and  bony  nature 
are  wandering  osteophytes,  and  are  evi- 
dences of  a  rheumatic  arthritis,  either 
manifest  or  latent.  Patterson  (Jour,  of 
Anat.  of  Insanity,  Apr.,  '90). 

Symptoms. — The  main  difference  be- 
tween the  symptoms  of  a  rheumatic  and 
simple  arthritis  is  that  those  of  the 
former  are  far  more  painful  both  to  the 
touch  and  also  to  movements.  Not  in- 
frequently the  signs  of  inflammation  run 
high,  and  then  the  joint  looks  red. 
When,  however,  the  course  is  more  sub- 
acute or  chronic  it  possesses  a  dead,  milk- 


white  look  that  is  highly  characteristic. 
Even  when  of  this  color  the  sensitiveness 
may  be  as  acute  as  ever.  Movements 
cause  great  pain,  and  in  long-standing 
cases  they  are  much  restricted.  Swell- 
ing is  present,  and  joints  are  apt  to  as- 
sume a  more  fusiform  shape  than  is  the 
case  in  a  simple  arthritis.  (Edema  may 
also  be  present.  Certain  portions  of  the 
joint  may  be  more  affected  than  others. 
Thus  I  have  seen  the  knee  swelled  at 
the  side  and  above  the  patella  and.  the 
shoulder  at  its  anterior  part.  In  some  of 
these  cases  the  adjoining  bursas  may  also 
be  affected. 

Treatment. — In  addition  to  the  meas- 
ures generally  used  for  simple  arthritis 
those  appropriate  for  the  rheumatic  di- 
athesis must  also  be  employed.  (See 
Eheumatism,  volume  v.) 

For  purposes  of  treatment,  rheumatic 
arthritis  should  be  carefully  differen- 
tiated from  rheumatoid  arthritis.  The 
former  is  an  affection  of  rheumatic  origin, 
local  in  character,  in  which  the  neural 
element  is  absent.  The  latter  is  a  general 
disease  of  debility,  having  no  connection 
with  rheumatism,  in  which  the  neural 
element  plays  a  conspicuous  part,  and 
which  occurs  in  cases  with  strong  heredi- 
tary histories  of  gout,  struma,  or  phthisis, 
its  last  stage  being  osteoarthritis.  Hugh 
Lane  (Lancet,  Dec.  10,  '92). 

It  is  important  to  bear  in  mind  that 
the  joint  is  to  be  protected  from  disturb- 
ing movements.  It  is  here  that  rheumatic 
differs  from  simple  traumatic  disease  of 
the  joints.  In  the  latter  a  small  amount 
of  movement  may  not  be  painful,  but  in 
the  former  the  opposite  is  the  case. 
Massage  is  not  apt  to  be  of  service  ex- 
cept in  chronic  cases,  certainly  not  in 
acute  ones.  Eest  on  a  splint  is  to  be  en- 
forced, with  the  joint  wrapped  up  in 
cotton  or  flannel.  The  application  of 
cloths  wrung  out  of  hot  alkaline  solu- 
tions may  be  tried.  A  piece  of  lint  wet 
with  chloroform  liniment  and  covered 


4—18 


274 


JOINTS.    RHEUMATIC  ARTHRITIS.  TREATMENT. 


with  woolen  cloths  may  give  relief. 
Osier  advises  the  use  of  the  Paquelin 
cautery,  lightly  and  rapidly  stroked  over 
the  part,  as  a  means  of  reducing  pain. 
The  use  of  leeches  is  not  so  efficacious  as 
in  traumatic  cases.  Cold  applications 
are  only  to  be  advised  when  not  dis- 
tressing to  the  patient.  The  use  of  hot- 
air  baths  must  be  decided  by  a  cautious 
trial.  The  heat  at  first  should  not  be 
great,  and  in  many  cases,  particularly 
acute  or  subacute  ones,  local  hot-air 
baths  are  not  to  be  used  at  all. 

Literature  of  '96-'97-'98. 

Attention  called  to  an  apparatus  em- 
ployed in  a  series  of  cases  in  the  Uni- 
versity Hospital,  where  some  three 
hundred  baths  were  given  to  test  its 
efficiency.  It  was  found  to  be  most 
satisfactory.  The  cases  that  were  treated 
included  acute  and  chronic  articular 
rheumatism,  gonorrhceal  rheumatism, 
gout,  traumatic  arthritis,  synovitis, 
tenosynovitis,  and  fibrous  ankylosis. 

The  method  of  administering  the  bath 
is  as  follows:  The  patient's  pulse  and 
temperature  are  first  taken  and  recorded. 
The  limb,  first  being  completely  envel-  I 
oped  in  a  piece  of  lint,  which  is  wrapped  j 
loosely  about  the  part,  is  then  placed  in 
the  cylinder.  The  time  allowed  for  each 
bath  is  from  three-fourths  of  an  hour  to 
an  hour.  At  intervals  of  twenty  min- 
utes the  door  of  the  cylinder  is  thrown 
open  momentarily  to  allow  of  the  ingress 
of  a  fresh  supply  of  air.  If  the  patient 
perspires  freely,  this  opportunity  is  taken 
advantage  of  to  wipe  the  limb  thoroughly 
dry.  If  this  precaution  is  not  taken  and 
the  limb  is  allowed  to  remain  bathed 
with  sweat,  there  is  the  possibility,  if  the 
temperature  is  exceedingly  high,  of  a 
superficial  burn's  resulting. 

The  degree  of  temperature  employed 
varies,  some  patients  bearing  with  perfect 
comfort  a  degree  of  heat  which  would  be 
extremely  painful  to  others.  The  average 
is  about  300°  F.  The  frequency  with 
which  the  baths  are  given  varies  with  the 
severity  of  the  case:  usually,  however, 
they  are' administered  on  every  other  day. 

Permanent  cures  of  local  lesions,  symp- 


tomatic of  diathetic  diseases,  are  not  to 
be  looked  for  from  the  employment  of 
hot-air  baths,  but  for  the  relief  of  joint- 
affections  of  traumatic  origin  this  method 
of  treatment  is  most  useful  and  some- 
times indispensable,  and  the  results  ob- 
tained can  be  called  permanent.  C.  H. 
Frazier  (Annals  of  Surg.,  Oct.,  '97). 

Case  of  chronic  rheumatic  arthritis 
treated  for  a  period  of  six  months  with 
hot-air  baths.  The  patient,  a  man  of  27 
years,  had  a  severe  attack  of  rheumatism 
three  years  before  coming  under  notice, 
which  lasted  for  five  months.  He  was 
left  crippled  and  bedridden  with  crooked 
spine,  stiff  arms  and  hips,  and  tucked  up 
knees.  For  three  years  he  was  practically 
bedridden.  Six  months'  treatment  with 
gentle  massage,  iron,  and  arsenic  im- 
proved him  a  little,  but  he  was  still  un- 
able to  walk  or  even  feed  himself.  At 
the  present  time  he  can  walk  well,  dress 
and  feed  himself,  and  has  increased  four 
inches  in  stature.  The  baths  given  were 
the  ordinary  blanket  baths  heated  by 
means  of  spirit-lamps  under  a  cradle  in 
bed.  Short  (Birmingham  Med.  Rev., 
May,  '98). 

General  hot-air  baths  and  also  Turk- 
ish baths  are  far  more  apt  to  be  of  service 
in  all  cases. 

Literature  of  '96-'97-'98. 

In  treatment  of  arthritis  by  hot-air 
baths  the  patient  lies  in  bed.  The  tent 
which  covers  him  is  made  of  two  large 
cradles,  covered  first  with  blankets,  then 
with  mackintosh  sheets,  and  then  again 
with  blankets.  The  coverings  must  he 
arranged  at  the  top  of  the  tent  in  such 
a  manner  that  a  small  opening  can  he 
made  to  let  out  the  hot  air  when  it  has 
become  saturated  with  moisture.  It" 
the  packing  he  too  tight,  a  counter- 
opening  must  be  made.  The  patient's 
neck  should  he  wrapped  as  air-tight  as 
possible.  The  cradles  used  are  made  of 
wire  netting  on  a  metal  frame.  The  flue 
attached  to  the  lamp  passes  through  an 
Opening  in  the  blankets  at  the  foot  of 
the  tent,  and  may  be  covered  with  as- 
bestos or  a  wet  (doth  to  proteet  the 
blanket.  The  lamp  should  be  made  with- 
out solder.    The  blanket  which  has  cov- 


JOINTS.    GOUT,  ARTHRITIS  OF. 


275 


ered  the  body  is  removed  finally  to  allow 
of  free  evaporation  from  the  surface  of 
the  skin.  The  patient  is  wiped  down 
after  the  bath,  and  wrapped  in  dry 
blankets  for  the  rest  of  the  day. 

As  a  rule,  an  opening  need  not  be  made 
till  the  patient  breaks  out  in  a  good 
perspiration  or  complains  of  feeling  too 
hot.  The  opening  should  be  made  at  the 
top  of  the  tent.  This  is  the  important 
point  in  the  treatment. 

This  treatment  is  applicable  to:  — 

1.  Subacute  rheumatic  arthritis. 

2.  Subacute  arthritis  following  acute 
rheumatism,  or  rheumatoid  arthritis,  as- 
sociated with  pain  and  stiffness  on  move- 
ment, with  continual  aching  pains. 

3.  Impaired  mobility  following  injuries 
to  joints  or  to  muscles  in  their  neighbor- 
hood, and  cases  of  joint-trouble  from  tro- 
phic causes  or  disuse.  T.  Sydney  Short 
(Brit.  Med.  Jour.,  Nov.  26,  '98). 

Too  vigorous  local  treatment  is  very 
apt  to  relight  the  trouble;  coaxing,  and 
not  forcing,  is  our  motto.  This  is  true 
also  of  passive  motion.  What  is  gained 
by  gentle  persistent  motion  is  apt  to  be 
retained,  but  what  is  acquired  by  forcible 
movements  under  anaesthesia  is  apt  to 
be  lost  and  the  joint  remain  stiff er  than 
before.  Notwithstanding  the  assertion 
of  Treves  ("System  of  Surgery/'  volume 
i,  page  267),  that  rheumatism  and  gout 
have  practically  no  effect  on  the  imme- 
diate future  of  an  operation,  care  should 
be  exercised.  In  disabilities  resulting 
from  loss  of  motion  in  joints  partial  op- 
erations are  liable  to  be  extremely  un- 
satisfactory, and  only  start  the  trouble 
anew,  as  I  have  seen,  and  the  total  re- 
moval is  more  satisfactory.  Thus,  in  the 
elbow-joint  a  formal  incision  is  apt  to 
give  a  better  result  than  the  removal  of 
exostoses.  In  one  case  I  deliberately  ex- 
cised the  joint  of  the  big  toe  for  an  in- 
tractable rheumatic  inflammation  that 
had  lasted  over  a  year,  resulting  in  par- 
tial disorganizing  of  the  joint.  While  it 
is  possible  that   rheumatism   may,  at 


times,  have  a  septic  element  in  it,  the 
practice  of  tapping  and  washing  the  joint 
with  a  mild  antiseptic  solution  is  only 
to  be  followed  with  caution  and  in  se- 
lected cases. 

As  a  treatment  for  chronic  rheumatic 
arthritis  it  is  advised  that  the  patient  be 
chloroformed,  the  joints  freely  and  fear- 
lessly moved,  and  the  flexors  and  exten- 
sors roughly  massaged.  Collins  (Brit. 
Med.  Jour.,  Apr.  19,  '90). 

Literature  of  '96-'97-'98. 

Heroic  treatment  of  acute  rheumatism 
by  means  of  opening  and  draining  the 
affected  joints  advocated.  Operation 
should  be  performed  as  soon  as  one  joint 
is  definitely  affected,  in  order  to  save 
other  joints  and  the  endocardium.  Gen- 
eral toxaemia  disappears  when  the  af- 
fected joints  are  irrigated  and  drained. 
The  incision  into  the  joint  must  be  large 
enough  to  admit  the  index-finger  in  order 
to  remove  the  coagulated  lymph.  Irri- 
gation with  1  in  5000  solution  of  bini- 
odide  of  mercury  and  potassium  is  best. 
The  joints  should  be  dried  with  a  long 
roll  of  gauze  in  order  in  drying  to  re- 
move all  flocculi.  The  joint  should  be 
drained  by  a  gauze  drain.  J.  O'Conor 
(Annals  of  Surg.,  Feb.,  '98). 

Gout,  Arthritis  of. 

Gout  is  certainly  less  common  in  this 
country  than  abroad.  On  this  account 
it  may  not  be  recognized  at  first  sight. 
It  attacks  all  the  joints,  but  most  fre- 
quently the  metacarpo-phalangeal  joint 
of  the  big  toe.  It  may  present  itself  in 
an  acute  form,  affecting  only  one  joint, 
or  in  a  more  chronic  form.  This  latter  is 
usually  preceded  by  the  former.  So  that 
the  chronic  form  of  the  disease  may  be 
largely  the  remains  of  several  acute  at- 
tacks. The  changes  produced  in  the 
parts  are  marked,  as  is  also  at  times  the 
resultant  disability.  The  cartilages  are 
apt  to  be  first  attacked  and  then  the  sur- 
rounding structures.  Frate  of  soda  is 
deposited  in  the  joint  on  the  articular 


276 


JOINTS.    CHARCOT'S  DISEASE. 


cartilages  and  through  them,  in  the  cap- 
sular ligaments,  and  even  surrounding 
tissues.  To  such  an  extent  is  this  latter 
the  case  that  gouty  nodules  of  urate  of 
soda  deposited  on  the  knuckles  not  in- 
frequently ulcerate  through  the  skin. 

Literature  of  '96-'97-'98. 

Statistics  of  the  location  of  the  pain 
in  cases  of  gout  and  rheumatism  occur- 
ring in  Roosevelt  Hospital. 

In  all  diarthritic  joints  the  painful 
points  in  gouty  inflammation  were,  with 
certain  specific  exceptions,  on  the  con- 
dyles. In  acute  rheumatic  arthritis,  on 
the  other  hand,  the  pain  w  as  more  dif- 
fused, but  distinctly  pronounced  along 
the  tendons,  and  at  their  attachments, 
but  not  on  the  condyles.  In  rheumatoid 
arthritis  there  was  no  uniformity  in  the 
localization  or  tenderness  on  pressure. 
In  gout  the  periosteum  was  chiefly 
affected,  and  in  rheumatism  the  sub- 
stance of  the  bone.  W.  H.  Thomson 
(Amer.  Medico-Surg.  Bull.,  Aug.  16,  '96). 

The  treatment  of  an  acute  attack  is 
to  be  sedative,  but  not  too  depleting. 
This  subject  is  fully  treated  under  Gout, 
volume  hi.  Surgical  measures  are  rarely 
required.  When  the  chalky  deposits  are 
marked,  and,  if  they  are  loose,  the  skin 
may  be  incised  and  the  deposit  turned 
out.  Care  should  be  taken  not  to  injure 
the  skin  over  these  deposits  or  it  may 
ulcerate  and  leave  an  Exceedingly  annoy- 
ing sinus. 

Charcot's  Disease. 

This  name  is  applied  to  the  joint- 
affections  which  at  times  accompany 
locomotor  ataxia.  Charcot  estimated 
that  they  occurred  in  10  per  cent,  of  the 
cases  of  ataxia,  but  in  this  country,  at 
any  rate,  the  proportion  is  much  smaller. 
The  changes  produced  in  the  joint  re- 
semble to  a  considerable  extent  those 
present  in  osteoarthritis.  The  course 
of  the  affection,  however,  is  differ- 
ent.   There  are  the  same  cartilaginous 


changes,  with  first  fibrillation  and  then 
disappearance.  There  is  a  marked  in- 
crease of  synovial  fluid,  bulging  out  the 
joint  usually  more  marked  than  in  osteo- 
arthritis, and  there  are  the  same  ridges 
of  bone,  with  occasional  nodules.  The 
disorganization  of  the  joint  is  apt  to  be 
more  rapid  and  more  marked.  Whereas 
a  joint  affected  with  osteoarthritis  tends 
to  ankylose,  that  affected  with  Charcot's 
disease  becomes  loose  and  flail-like.  Pain 
is  a  marked  symptom  in  the  former:  In 
the  latter  it  is  only  present  to  any  extent 
in  the  early  stages,  to  be  replaced  later 
by  anaesthesia.  Even  the  bones  wear 
away  as  if  from  pressure.  It  usually  at- 
tacks single  joints,  but  both  knees  may 
be  affected  or  the  elbow  and  fingers.  At 
times  its  course  is  rapid  disorganization 
occurring  in  a  few  weeks,  and  this  in- 
dependently of  the  fact  of  use  of  the 
joints.  These  cases  are  of  particular  in- 
terest to  the  surgeon,  because  he  is  liable 
to  be  consulted  before  the  ataxic  disease 
has  been  recognized,  and  their  true  char- 
acter is  liable  to  be  overlooked.  When- 
ever an  adult  patient  comes  with  a  joint 
largely  distended  with  fluid,  with  com- 
paratively slight  pain,  and  with  symp- 
toms apparently  too  mild  for  the  evident 
destructive  lesions  present,  then  one 
should  search  for  ataxic  symptoms. 

Possibility  of  the  occurrence  of  marked 
joint- lesions  before  the  symptoms  of  spi- 
nal disease  manifest  themselves  to  any 
great  extent.  Attention  called  to  the 
close  similarity  between  the  joint-lesions 
of  tabes  dorsalis  and  those  of  syringo- 
myelia ;  but.  while  the  former  disease 
affects  the  lower  extremities  (76  per 
cent.),  the  latter  confines  itself  to  the 
upper.  Osteomata  of  the  tendons,  mus- 
cles, etc..  are  found  in  both  diseases,  but 
more  frequently  in  syringomyelia.  If 
only  the  local  conditions  were  considered, 
it  would  be  difficult  to  differentiate  the 
two  affections.  The  joint-lesions  may  be 
divided  into  the  atrophic  form,  which  is 
rare,  and  the  hypertrophic  form,  which 


JOINTS.    SEPTIC  ARTHRITIS. 


is  more  common.  Charcot  (Le  Prog. 
M.'d.,  Apr.  29,  '93). 

Locomotor  ataxia  manifests  itself  by 
inco-ordination  of  movements,  want  of 
ability  to  balance  one's,  self,  especially 
with  the  eyes  closed,  by  shooting  pains 
in  the  lower  extremities,  also  gastric  dis- 
turbances. The  pupils  do  not  react  to 
light,  but  do  to  accommodation, — the 
Argyl-Eobertson  pupil.  The  reflexes  be- 
come lost,  there  may  be  ptosis  or  stra- 
bismus, or  even  a  commencing  optic 
atrophy,  and  as  the  disease  advances 
paraplegia  with  loss  of  control  of  the 
sphincters.    (See  Locomotor  Ataxia.) 

Treatment. — The 'disease  is  practically 
incurable.  When  it  seems  very  active 
complete  rest  may  be  enjoined,  but  when 
it  is  slow,  then  supports  may  be  applied 
to  the  joints  so  that  they  can  be  used  as 
long  as  possible.  It  is  in  the  highest  de- 
gree advisable  not  to  subject  these  joints 
to  operative  procedures.  It  is  a  great 
temptation  to  recommend  the  removal  of 
a  limb  whose  knee-joint  is  absolutely 
disorganized;  but  doing  so  may  result  in 
the  death  of  the  patient,  because  the  at- 
tempt at  healing  may  be  slight  or  totally 
lacking. 

Conservative  and  palliative  treatment 
is  to  be  advised  and  the  joint  given  all 
the  support  possible.  Of  course,  the 
treatment  proper  for  ataxia  is  to  be 
given,  as  well  as  local  attention  to  the 
affected  joint. 

Septic  Arthritis. 

The  joints  frequently  are  attacked  by 
an  inflammation  of  a  septic  character 
while  there  co-exists  a  septic  disease  af- 
fecting the  body  generally.  This  infec- 
tion is  caused  by  a  pus-producing  or- 
ganism, the  staphylococcus.  Pyaemia, 
typhoid  and  other  fevers,  and  the  puer- 
peral state  are  the  diseases  most  often  ac- 
companied by  septic  joint-affections. 

Inasmuch  as  the  condition  is  much  the 


same  in  all,  they  present,  to  a  great  ex- 
tent, similar  symptoms.  The  joint  be- 
comes the  seat  of  an  effusion,  usually 
with  pain.  Sometimes  only  one  joint  is 
affected.  When  such  is  the  case  it  is 
apt  to  be  a  large  one,  as  the  knee  or  hip. 
This  is  frequently  the  case  in  puerperal, 
typhoid,  and  other  fevers. '  In  pyaemia 
several  joints  are  apt  to  be  attacked. 
The  onset  is  liable  to  be  very  insidious 
and  may  be  passed  unnoticed,  being 
masked  by  the  symptoms  of  the  general 
affection.  The  pain  in  the  joint  may 
produce  a  restlessness  which  may  be  at- 
tributed to  nervous  or  other  disturbance; 
so  that  the  disease  may  be  far  advanced 
when  recognized.  Sometimes  the  local 
disease  progresses  with  great  rapidity, 
pus  being  present  in  the  joint  almost 
from  the  first. 

Literature  of  '96-'97-'98. 

Although  acute  arthritis  and  epiphy- 
sitis occur  most  frequently  and  most 
typically  in  infants  under  a  year  old. 
practically  the  same  condition  is  ob- 
served in  much  older  children.  In  the 
latter  an  epiphysitis  is  less  likely  to 
cause  suppuration  of  the  joint,  or,  if  it 
does  so,  this  occurs  later.  The  disease 
frequently  proves  fatal  in  three  or  four 
days,  and  the  knee  is  more  frequently 
affected  than  any  other  joint,  being  fol- 
lowed in  frequency  by  the  hip,  and  then 
the  shoulders.  The  primary  lesion  is  an 
osteomyelitis,  situated  in  the  growing 
bone  at  the  extremity  of  the  diaphysis, 
and  in  close  proximity  to  the  epiphysial 
disk.  Therefore  separation  of  the  epiph- 
ysis frequently  follows,  and  an  abscess 
occupies  the  epiphysial  line.  In  older 
children  a  precisely  similar  lesion  in  the 
neighborhood  of  the  epiphysial  line  may 
give  rise  to  the  condition  known  as  acute 
necrosis  or  acute  periostitis.  The  septic 
products  make  their  way  between  the 
periosteum  and  the  bone,  the  former  be- 
ing stripped  off  for  a  longer  or  shorter 
distance.  Eve  (Clinical  Journal.  Oct.  13, 
'97). 

The  joint  swells  and  effusion  is  usu- 


278 


JOINTS.    SYPHILITIC  ARTHRITIS. 


ally  easily  diagnosed.  On  the  contrary, 
the  first  symptom  may  be  pain.  Pain  is 
a  very  constant  symptom  of  general  sep- 
sis and  pains  in  various  parts  of  the  body 
may  be  complained  of  before  any  definite 
joint  disease  is  visible.  The  color  of  the 
skin  over  the  joint  is  not  apt  to  be 
changed  at  first;  but,  if  disorganization 
of  the  joint  takes  place,  then  it  may  be- 
come red  and  (Edematous.  In  the  hip- 
joint,  which  is  exceedingly  liable  to  be- 
come affected  in  typhoid  fever,  disloca- 
tion is  very  apt  to  occur.  If  the  hip 
trouble  occurs  early  in  the  course  of  the 
general  disease,  it  may,  as  in  one  case  in 
my  own  experience,  be  difficult  to  diag- 
nose the  condition  from  acute  hip  dis- 
ease of  a  tubercular  character.  Multi- 
plicity of  lesions  always  argues  for  a 
general  infection;  therefore,  when  more 
than  one  joint  is  affected,  one  is  almost 
sure  that  the  disease  is  only  a  local  mani- 
festation of  a  general  condition  instead 
of  being  a  distinct  and  separate  local  dis- 
ease. Oftentimes  if  the  general  disease 
tends  to  recovery  the  local  joint  trouble 
may  be  more  of  the  nature  of  a  synovitis 
than  an  arthritis,  and  may  pursue  a  mild 
course,  particularly  if  only  a  single  joint 
is  affected.  If,  however,  the  general  dis- 
ease is  grave  the  local  disease  is  of  a 
purulent  character  almost  from  the  start, 
and  suppuration  may  persist  a  long  time, 
until  death  finally  ends  all. 

Treatment. — At  the  onset  of  the  joint 
trouble  measures  should  be  taken  to 
soothe  the  irritation  of  the  joint  and  pro- 
tect it.  It  may  be  surrounded  with  cot- 
ton, or  lint  wet  with  lead  water,  and  sup- 
ported by  leather  or  pasteboard  splints. 
Sand-bags  may  also  be  placed  on  either 
side  and  an  ice-cap  laid  on  the  joint. 
Sometimes  enveloping  the  part  in  hot 
cloths  is  most  comfortable.  A  conserva- 
tive course  should  be  pursued  as  long  as 
the  disease  is  not  progressing  too  fast. 


If  it  assumes  a  chronic  form  the  joint 
may  be  wrapped  in  lint  spread  with  bella- 
donna and  mercury  ointment  or  one  of 
10-  to  20-per-cent.  ichthyol,  and  sup- 
ported by  a  firm  bandage  and  splints. 
If,  however,  the  joint-symptoms  become 
very  active,  it  should  be  aspirated  and 
washed  out  with  sterile  salt  solution  or 
boric  acid  or  weak  bichloride  solution. 

Case  of  acute  suppuration  of  the  knee- 
joint  treated  by  a  thirty  days'  continu- 
ous irrigation  with  a  weak  solution  of 
boric  acid,  a  good  and  movable  joint  be- 
ing secured.  Treves  (Brit.  Med.  Jour., 
July  7,  '88). 

Case  due  to  suppurative  inflammation 
of  knee-joint.  Motion  completely  re- 
stored by  daily  use  of  apparatus  consist- 
ing of  weight  and  rope,  latter  attached 
to  ankle.  Bradford  (Med.  Rec,  June  8. 
'95). 

If  suppuration  becomes  marked,  free 
incision  with  drainage  may  be  necessary. 

In  these  cases  free  stimulation  to  sup- 
port the  general  strength  is  of  the  great- 
est importance,  because  they  are  liable 
to  last  quite  a  long  while  and  eventually 
kill  the  patient  by  gradual  exhaustion. 
In  suppurative  conditions  of  the  wrist 
and  in  compound  ganglion  relief  afforded 
by  subcutaneous  division  of  the  anterior 
annular  ligament.    Stillman  (Bull.  Gen. 
de  Ther.,  Mar.  8,  '90). 

Syphilitic  Arthritis. 

Syphilis  attacks  the  joints  the  same  as 
it  does  other  tissues.  It  may  occur  in 
infancy,  from  heredity,  in  the  secondary 
stage,  or  in  the  tertiary.  In  infancy,  as 
well  as  to  a  somewhat  less  extent  in 
adults,  the  disease  is  to  be  diagnosed  and 
recognized  not  so  much  by  its  own 
peculiarities  as  by  its  surroundings  and 
associations.  If  there  is  any  point  that 
may  be  more  noticeable  in  it  than  in 
other  affections  of  the  joint,  it  is  its 
less  acute  and  less  painful  course.  In 
infancy  the  joint,  particularly  the  knee, 
may  become  swelled  and  somewhat — but 


JOINTS.    SYPHILITIC  ARTHRITIS.  TREATMENT. 


279 


not  exceedingly — painful,  nor  very  red, 
but  be  held  stiff,  and  accompanied  by 
atrophy  of  the  muscles.  There  is  usu- 
ally present  other  manifestations  of  the 
disease,  such  as  skin  eruptions,  eye  af- 
fections, notched  or  pegged  teeth,  etc. 
A  syphilitic  history  may  also  often  be 
traced  in  the  parents.  As  I  have  seen 
it  in  infancy  it  assumes  mostly  the  syno- 
vial type  and  yields  to  specific  treatment. 
The  disease  also  attacks  the  joints  in  the 
secondary  stage.  It  then  shows  itself  as 
an  effusion  into  the  joints,  resembling 
very  much  rheumatism,  but  not  in  a. 
highly-acute  form.  One's  attention  to  its 
true  character  will  probably  be  attracted 
by  the  other  secondary  symptoms.  The 
disease  of  the  joint  will  assume  a  mild 
acute  or  a  subacute  form.  In  the  tertiary 
stage  of  syphilis  the  joint  disease  is  mani- 
fested by  a  deposit  of  gummatous  tissue 
in  the  various  parts  of  the  joint.  The 
swelling  may  be  more  irregular  than  in 
rheumatic  disease,  from  the  deposit's  oc- 
curring in  some  portions  of  the  joint 
while  other  portions  are  free.  As  a  rule, 
it  does  not  occasion  suppuration,  al- 
though ankylosis  may  occur.  This  may 
be  fibrous  or  even  bony. 

Syphilitic  bursitis  may  be  met  with  in 
connection  with  secondary  or  tertiary 
lesions.  Buechler  (Med.  Monats.,  Aug., 
'89). 

During  the  last  year  and  a  half  328 
cases  of  joint-inflammation  personally 
observed,  of  which  01/,  per  cent,  were 
syphilitic  in  origin.  The  capsule  in  syphi- 
litic inflammation  of  joints  often  becomes 
hardened  in  spots,  and  lacks  the  uniform, 
doughy  feel  of  tuberculosis.  Nocturnal 
pains  noticed  in  syphilis.  Rubinstein 
(Inter,  klin.  Rund.,  Sept.  28,  '90). 

Secondary  syphilitic  arthritis  may  pre- 
sent itself  in  three  forms:  (1)  arthralgia 
giving  rise  to  no  apparent  lesion;  (2) 
subacute  arthritis;  (3)  hydrarthrosis. 
The  duration  of  the  disease  is  short,  not 
exceeding  two  weeks,  and  there  is  no  in- 
volvement of  the  heart  or  the  viscera. 


Cheminade  (Ann.  de  Derm,  et  de  Syph., 
July  25,  '88). 

Following  division  made  of  joint-syphi- 
lis: 1.  Synovitis,  during  the  secondary 
stage.  This  usually  occurs  within  a  few 
months  of  infection,  is  of  but  short  dura- 
tion, is  very  amenable  to  mercurial  treat- 
ment, and  clears  off,  leaving  no  trace  be- 
hind. It  is  rarer  and  of  far  less  impor- 
tance than  the  other  forms,  which  all 
occur  during  the  tertiary  stage.  2.  Peri- 
synovial  gummata.  3.  Arthritis  due  to 
osseous  nodes  or  gummata  in  the  neigh- 
borhood of  the  joint.  4.  True  chronic 
synovitis.  5.  Syphilitic  chondroarthritis 
(Virchow).  To  the  above  forms  are 
added  two  others,  as  occurring  in  heredi- 
tary syphilis:  (6)  syphilitic  epiphysitis 
and  (7)  chronic  effusion  into  the  joints, 
usually  the  knee,  and  almost  always 
associated  with  interstitial  keratitis. 
Hutchinson  (Brit.  Med.  Jour.,  Apr.  10, 
'92). 

In  syphilitic  arthritis  there  is  but  slight 
functional  disturbance  of  the  joint,  and 
the  prognosis  is  generally  a  favorable  one. 
Kirmisson  (Le  Bull.  Med.,  May  29,  '89). 

Treatment. — If  the  true  nature  of  the 
disease  is  recognized,  antisyphilitic  meas- 
ures are  to  be  employed.  In  infancy 
mercurial  inunctions  are  best.  In  adults 
inunctions  are  desirable  if  it  can  be  made 
convenient  to  use  them, — if  not,  then 
internal  medication.  The  biniodide  of 
mercury  beginning  with  about  1/24  grain 
and  rapidly  increasing  to  a  quarter  or 
more  three  times  daily  is  my  preference. 
The  green  iodide  of  mercury  1/4  grain 
three  times  daily  or  a  mixture  of  bichlo- 
ride of  mercury  and  iodide  of  potassium 
or  sodium  in  compound  syrup  of  sarsa- 
parilla  are  also  favorite  forms  of  medica- 
tion. In  doubtful  cases  iodide  of  potas- 
sium or  sodium  should  be  given,  as  it 
is  likely  to  be  of  benefit  whether  the  case 
is  one  of  syphilitic  or  rheumatic  origin. 
Locally  the  methods  used  for  other  forms 
of  arthritis  are  to  be  used,  but  the  joint 
may  be  covered  with  lint  spread  with 
belladonna  and  mercury  ointment. 


280 


JOINTS.    TUBERCULAR  ARTHRITIS.  SYMPTOMS. 


Tubercular  Arthritis.  (See  also  Hip- 
joint  Disease,  volume  iii.) 

Tubercular  arthritis  is  the  name  given 
to  what  was  formerly  known  as  scrofu- 
lous or  strumous  disease  of  the  joints. 
When  the  knee-joint  was  affected,  it  was 
called  tumor  albus;  it  has  also  been 
called  gelatinous  arthritis.  It  is  now 
positively  known  that  the  characteristics 
of  this  disease  are  due  to  the  tubercle 
bacillus,  and  that  in  its  pathology  it  is 
a  true  tuberculosis  affecting  the  bones 
and  joints.  The  tubercular  process  is  a 
local  one;  it  may  and  often  does  occur 
in  company  with  other  tuberculous 
manifestations  elsewhere,  but  it  is  late 
in  the  course  of  the  disease.  The  tuber- 
cle bacillus  becomes  disseminated  and 
starts  up  tubercular  processes  elsewhere. 

In  the  commencement,  the  joint,  or 
the  adjacent  bone,  alone  is  affected.  The 
part  becomes  infiltrated  with  small  cells, 
giant  cells  form;  caseation,  pus,  and 
necrosis  forms;  and  the  bones  become 
destroyed  and  the  joint  disorganized. 
The  origin  of  the  disease  process  is  of 
the  greatest  importance.  Cases  occur 
which  look  clinically  as  if  the  joint  alone 
was  involved;  as  if  it  was  the  seat  of  a 
tubercular  synovitis  and  that  alone.  In 
other  cases  it  is  evident  that  disease  of 
the  bone  is  present,  as  well  as  of  the 
synovial  membrane.  Almost  all  surgical 
authors  describe  these  two  forms  of  joint- 
tuberculosis.  Most  of  them  regard  the 
osseous  form  as  being  the  more  frequent, 
but  also  that  the  synovial  form  is  very 
common. 

Recently  Edward  H.  Nichols,  of  Bos- 
ton, read  before  the  American  Ortho- 
paedic Association  an  elaborate  paper  on 
joint-tuberculoses,  and  he  states  as  his 
opinion  that  primary  synovial  tuberculo- 
sis is  exceedingly  uncommon,  and  that 
of  120  tubercular  joints  he  has  not  seen 
one  in  which  on  sawing  open  all  the 


bones  in  thin  layers  one  or  more  old 
bone  foci  were  not  found.  I  am  inclined 
to  believe  that  he  is  right  in  his  opinion 
and  that  those  joints  which  have  been 
examined  and  pronounced  to  be  synovial 
tuberculosis  would  have  showed  in  most 
cases  to  have  bony  involvement  if  the 
bone  had  been  examined  in  a  number  of 
thin  sections.  Whatever  the  true  pathol- 
ogy of  tubercular  joint  diseases  is,  they 
certainly  manifest  themselves  clinically 
in  the  two  forms. 

Symptoms. — Joint-tuberculosis,  while 
essentially  a  chronic  affection,  still  some- 
times runs  an  acute  course.  When  it 
does  so,  it  may  exhibit  all  the  signs  of 
inflammation, — viz.:  heat,  redness,  swell- 
ing, pain,  and  disturbance  of  function. 
Commonly,  however,  the  disease  begins 
insidiously.  Disturbance  of  function  is 
apt  to  be  the  first  symptom,  particularly 
if  the  hip  or  knee  is  affected.  The  skin 
orinarily  remains  white,  the  joint  be- 
comes swelled,  due  to  the  swelling  of  the 
synovial  membrane  and  increase  of  fluid. 
Pain  begins  gradually,  and,  while  some- 
times almost  entirely  absent,  at  others  is 
felt  only  on  use  of  the  joint.  Eedness 
occurs  when  pus  has  formed  and  is  work- 
ing its  way  toward  the  surface.  This 
occurs  usually  at  certain  definite  spots 
which  break  down  and  form  sinuses 
which  lead  down  to  carious  bone  and  in 
cases  of  long  standing  directly  into  the 
joint.  The  pain  is  felt  in  the  joint  itself, 
in  the  epiphyseal  ends  of  the  bones,  and 
in  certain  cases  in  distant  parts  as  the 
pain  along  the  inner  side  of  the  knee  in 
hip  disease.  As  the  disease  progresses 
the  joint  becomes  disorganized,  pieces  of 
bone  exfoliate,  sequestra  are  formed,  the 
I  general  health  deteriorates,  and  in  a  cer- 
tain number  general  tuberculosis  ensues 
and  causes  death. 

Almost  any  joint  can  become  affected, 
but  the  most  commonly  attacked  are  the 


JOINTS.    TUBERCULAR  ARTHRITIS.  TREATMENT. 


281 


spine,  hip,  knee,  ankle,  elbow,  and  wrist. 
The  small  bones  and  joints  of  the  foot 
and  hand  -are  also  not  seldom  involved. 

Treatment. — Tubercular  disease  of  the 
bones  and  joints  is  not  so  serious  a  dis- 
ease as  is  that  of  the  lungs.  The  patients 
usually  recover;  but  are  left  in  a  more  or 
less  crippled  condition  according  to  the 
severity  of  the  affection.  As  so  many  pa- 
tients preserve  a  fair  state  of  general 
health,  while  possessing  a  diseased  joint, 
the  local  treatment  becomes  more  impor- 
tant than  the  constitutional.  In  other 
words,  the  best  way  to  improve  the  gen- 
eral health  is  to  better  the  joint  affection. 
Attempts  to  "build  up  the  system"  while 
neglecting  the  local  trouble  will  only  end 
in  disaster.  The  main  element  of  local 
treatment  is  rest.  Tubercular  attacks 
often  follow  injuries.  Not  only  is  this 
so,  but  the  disease  is  kept  active  by  re- 
peated, slight  irritations  due  to  move- 
ments and  use  of  the  part.  Therefore 
protection  is  required.  The  more  acute 
and  marked  the  trouble  the  more  abso- 
lute must  the  rest  be.  It  is  practically 
impossible  to  secure  this  when  the  spine 
or  knee  or  hip  are  affected  unless  the 
patient  is  placed  in  bed.  Parents,  and 
even  physicians  sometimes,  think  that 
prolonged  rest  in  bed  will  be  injurious 
to  the  general  health,  but  experience  has 
abundantly  proved  that  this  is  not  so, 
and  whenever  it  is  possible  to  do  so  the 
patient  should  be  put  abed  and  kept  on 
his  back  until  all  symptoms  of  activity 
of  the  disease  have  subsided.  This 
should  be  done  for  months  or  even  a 
year  or  two  if  necessary.  In  order  to 
keep  small  children  in  bed  and  to  prevent 
their  setting  up,  it  is  desirable  to  fasten 
them  down  by  means  of  a  towel  passed 
across  the  chest  and  pinned  fast  with 
safety  pins  to  the  mattress.  Bradford 
devised  a  frame  of  iron  gas-pipe  to  sur- 
round the  child  and  covered  with  canvas 


or  unbleached  muslin.  The  child  may 
be  fastened  to  this  by  means  of  a  sort 
of  apron  passing  across  the  chest  with 
straps  passing  over  the  shoulders.  This 
is  useful  in  affections  of  the  hip  as  well 
as  of  the  spine.  Extension  is  of  service 
in  diseases  of  the  hip  and  knee;  its  ob- 
ject is  to  keep  the  joint-surfaces  from 
being  pressed  together  by  muscular  con- 
traction. Its  good  effect  is  at  once  seen 
by  the  diminution  of  pain.  It  allays 
muscular  spasm.  Even  when  the  patient 
is  allowed  to  go  about,  the  same  object 
is  aimed  at  by  the  use  of  a  suitable 
apparatus. 

Literature  of  '96-'97-'98. 

Too  much  stress  cannot  be  laid  on  the 
necessity  of  early  and  complete  rest  for 
the  affected  joint  in  tubercular  arthritis. 
Weight  extension  continued  until  all 
pain  and  tenderness  have  long  subsided 
is  of  most  use.  When  an  abscess  has 
formed,  there  are  four  possible  lines  of 
treatment:  First,  merely  opening  and 
draining  abscesses  as  they  form.  This  is 
an  uncertain  method.  The  second  line  of 
treatment  can  only  be  adopted  when  the 
disease  is  purely  synovial — it  consists  in 
the  removal  of  all  the  diseased  synovial 
tissue,  and  may  be  expected  to  cure  that 
form  of  the  disease.  The  third  method  is 
by  excision.  Finally,  in  some  inveterate 
cases,  amputation  becomes  necessary. 
Gerald  R.  Baldwin  (Clinical  Jour.,  Jan. 
29,  '96). 

Mechanical  supports  or  splints  of  some 
kind  are  of  the  greatest  service.  Plaster 
of  Paris  and  silicate  of  soda  are  of  great 
utility.  Also  splints  made  of  pasteboard 
or  wood  or  leather.  When  quick  setting 
is  required  or  frequent  changing  then 
plaster  of  Paris  is  best.  When  the  pa- 
tient can  remain  in  bed  for  twent3>"-four 
hours  and  where  quick  setting  is  not  re- 
quired and  the  apparatus  is  to  be  worn 
for  a  considerable  time  then  silicate  of 
soda  is  preferable.  For  the  upper  ex- 
tremity splints  of  wood,  or  pasteboard  or 


282 


JOINTS.    TUBERCULAR  ARTHRITIS.  TREATMENT. 


leather  are  applicable;  but  these  various 
dressings  can  be  used  in  any  part  of  the 
body  and  the  choice  will  depend  on  the 
peculiarities  of  the  individual  case  and 
the  mechanical  abilities  of  the  surgeon. 
These  dressings  should  all  be  so  made  as 
to  be  removed  every  day  or  two,  so  that 
the  parts  can  be  inspected  and  bathed 
and  excoriations  prevented.  In  spinal 
disease  when  the  patient  is  not  fastened 
down  in  bed,  then  it  is  desirable  that  the 
apparatus  be  worn  during  the  night  as 
well  as  by  day;  it  insures  better  rest  to 
the  diseased  part.  Local  applications  do 
not  play  a  very  important  part  in  treat- 
ment. In  acute  cases  evaporating  lotions 
like  lead-water  may  be  applied  or  an  ice- 
cap laid  on  the  inflamed  joint.  When 
the  disease  becomes  more  chronic,  then 
ointments  like  belladonna  and  mercury 
and  10-per-cent.  ichthyol  may  be  used 
and  the  joint  firmly  bandaged  with  either 
a  flannel  or  rubber  bandage  or  it  may  be 
strapped  with  adhesive  plaster.  Some- 
times small  blisters  around  the  affected 
spot  tend  to  relieve  pain. 

Large  effusions  into  a  joint  may  be 
tapped  under  the  strictest  antiseptic  pre- 
cautions. If  pus  forms,  the  joint  may 
be  washed  out  with  a  1  to  5000  solution 
of  bichloride  of  mercury.  The  injection 
of  iodoform  and  glycerin  emulsion  10- 
per-cent.  into  and  around  the  joint  is 
spoken  of  favorably  by  Senn  and  others. 
Case  of  tuberculous  synovitis  of  the 

knee  cured  by  injections  of  iodoform-oil. 

Troquart  (Jour,  de  Med.  de  Bordeaux, 

Dec.  22,  '95). 

Literature  of  '96-'97-'98. 

Treatment  of  tubercular  osteoar- 
thritis confined  entirely  to  intra-articular 
injections  of  iodoform.  Because  of  the 
pain  attendant  upon  ethereal  solutions  of 
this  product,  a  mucilaginous  emulsion 
containing  33  per  cent,  of  iodoform,  lias 
been  used;  5  cubic  centimetres  of  this 
mixture  were  employed  at  a  dose. 

Injections  were  repeated  twice  a  week; 


when  improvement  was  slow  every  sec- 
ond day.   In  seven  cases  the  results  were 
very  satisfactory.     In  the  eighth  case, 
complicated  by  suppurating  sinuses,  re- 
section was  necessary;  the  ninth  required 
amputation.      Results    were  especially 
good  in  white  swelling  oi  the  knee-joint. 
Five  patients  treated  for  this  affection 
were  cured  in  from  four  to  six  months, 
and  the  cure  was  permanent,  Duplay 
and  Cazin  (Revue  de  Chir.,  Xo.  11,  '97). 
Inasmuch  as  the  diseased  process  is  so 
often  situated  in  the  bone,  Macnamara 
has  advocated  trephining.    I  have  often 
drilled  the  affected  bone  with  numerous 
holes   about   three-sixteenths   inch  in 
diameter,  and  it  has  been  of  great  serv- 
ice.   Earely  pus  may  be  found,  but  usu- 
ally not.    The  drilling,  however,  tends 
to  stop  the  progress  of  the  disease,  and  is 
worthy  of  more  extended  use  than  is  now 
practiced. 

The  question  of  operative  treatment 
in  tuberculous  cases  is  the  cause  of  much 
difference  of  opinion.  One  fact  is  well 
settled,  and  that  is  that  conservatism  is 
more  desirable  in  orthopaedic  cases  than 
in  those  of  general  surgery.  Abscesses 
may  be  opened  if  they  pursue  an  acute 
course  with  considerable  pain  and  dis- 
turbance of  the  patient.  If  they  are  cold, 
chronic,  and  not  too  large,  they  are  best 
let  alone,  as  many  of  them  will  entirely 
disappear.  Infection  is  very  liable  to  at- 
tack a  discharging  collection  of  pus,  and 
the  general  health  may  become  affected. 
Abscesses  may  be  emptied  with  a  trocar, 
washed  out  with  salt  solution  or  weak- 
antiseptic,  and  then  injected  with  10- 
per-cent.  iodoform  emulsion,  an  ounce  or 
more  being  used.  This  will  probably 
have  to  be  repeated,  perhaps  two  or  three 
times.  Sometimes  the  abscess  keeps  on 
discharging  without  any  tendency  to  heal 
until  death  from  exhaustion  or  general 
tuberculosis  supervenes.  Eesection  of 
joints  is  to  be  resorted  to  when  the  sup- 
puration is  so  profuse  as  to  endanger  life 


JOINTS,  LOOSE  BODIES  IN. 


283 


and  the  patient  is  of  a  suitable  age.  Re- 
sections in  young  children  interfere  so 
much  with  growth  as  not  to  be  advisable. 
In  these,,  partial  resections  or  erosions 
are  to  be  preferred,  the  joint  being 
opened  and  the  affected  tissue  cut  and 
gouged  away.  Operative  measures  are 
more  advisable  as  the  patient  increases 
in  age.  Amputation  is  only  to  be  re- 
sorted to  as  a  life-saving  measure,  usu- 
ally for  profuse  suppuration  with  entire 
disorganization  of  the  joint.  As  a  rule, 
patients  are  to  be  kept  in  bed  until  all 
evidence  of  acute  trouble  has  gone  and 
remained  away  for  two  or  three  months. 
Then  the  patient  may  be  allowed  to  go 
about  with  some  appliance  to  keep  the 
joint  from  moving,  or  with  a  high  shoe 
and  crutches.  These  protecting  appli- 
ances are  to  be  worn  for  months  after  all 
evidence  of  active  disease  has  passed 
away.  For  walking  cases  very  nice  ap- 
pliances may  be  made  of  silicate  of  soda, 
which  can  be  used  for  many  months. 
When  the  patient  can  afford  the  expense, 
an  apparatus  made  by  the  instrument- 
maker  is  much  preferable  for  all  of  the 
tuberculous  cases.  Its  style  will  vary 
with  the  character  of  the  case. 

General  treatment  is  to  be  used  along 
with  the  local.  The  remedies  are  well 
known:  codliver-oil  with  creasote,  syrup 
of  the  iodide  of  iron,  tincture  of  mix 
vomica,  and  compound  syrup  of  the  hy- 
pophosphites  are  those  most  commonly 
used.  The  late  Dr.  Goodman  used  a  pre- 
scription composed  of: — 

1}  Bichloride  of  mercury,  1/24  or  1/48 
grain. 

Fowler's  solution  of  arsenic,  1  to 
3  drops. 

Tincture  of  iron,  3  to  8  drops. 
Syrup  of  orange-flowers,  1  drachm. 
— M. 

It  is  a  very  efficient  combination,  and 


acts  well  in  many  cases.  Careful,  per- 
sistent, protective,  and  conservative 
treatment  is  the  key-note  of  success  in 
the  management  of  tuberculous  joint 
diseases. 

Loose  Bodies  in  Joints. 

Symptoms. — The  symptoms  of  the  af- 
fection are  marked,  and  are  due  to  inter- 
ference with  the  function  of  the  joint. 
The  knee  is  the  joint  most  often  affected. 
The  patient,  while  walking,  is  apt  to  ex- 
perience a  severe  pain  in  the  joint  and 
may  either  fall  or  else  hold  the  joint 
stiff.  It  may  become  locked.  In  some 
cases  the  patient  can  so  manipulate  the 
part  as  to  free  the  loose  body  and  then 
walking  again  is  possible.  These  sudden 
attacks  of  disability  are  followed  by  a 
swelling  of  the  joint  and  all  the  symp- 
toms of  an  acute  synovitis.  These  re- 
peated attacks  supervening  on  the  orig- 
inal injury  are  apt  to  cause  the  joint  to 
be  constantly  in  a  state  of  low  chronic 
inflammation  which  is  more  or  less  dis- 
abling. 

Pain  so  often  associated  with  the  pres- 
ence of  these  bodies  is  largely  due  to 
their  tearing  the  capsule  in  the  move- 
ments of  the  joint  and  not  to  their  being- 
caught  between  the  bones.  Riesenfeld 
(Breslauer  Aerzliche  Zeit.,  Jan.  28,  '88). 

Pain  occurring  with  foreign  bodies  in 
the  joints  regarded  as  due,  not  to  pinch- 
ing of  the  body  between  the  joint-sur- 
faces, but  to  stretching  of  the  capsule 
that  takes  place  when  the  body  lies  in 
certain  positions  outside  the  joint-sur- 
faces. Larsen  (Deut.  med.  Zeit.,  Apr.  24, 
'90). 

Besides  the  pain  and  stiffness  which 
may  be  produced,  the  patient  has  a  con- 
tinual sense  of  distrust,  which  causes  him 
to  avoid  using  the  joint  freely,  and  thus 
interferes  with  walking.  In  many  cases 
there  is  nothing  apparently  wrong  with 
the  joint  until  the  moment  of  pinching 
or  jamming  of  the  loose  body  as  the  joint 
is  in  motion.    These  patients  are  usu- 


284 


JOINTS,  LOOSE  BODIES  IN.  TREATMENT. 


ally  skillful  in  finding  and  localizing  the 
loose  body,  but  not  always.  Often  it  dis- 
appears on  the  slightest  movement,  not 
to  be  discovered  until  it  again  intrudes 
itself  upon  the  patient's  notice  at  some 
inopportune  moment. 

Loose  bodies  in  joints  are  usually  the 
result  of  injury  or  disease.  Many  are 
due  to  mere  masses  of  fibrin  and  show 
little  or  no  structure.  Whether  simple 
effused  blood  can  become  so  firm  and 
compacted  as  to  form  loose  bodies  is 
questionable;  ordinarily  such  effused 
blood  is  absorbed.  It  is  quite  probable, 
however,  that  some  of  the  milder  forms 
of  foreign  bodies  are  of  this  character. 
The  synovial  membrane  is,  however,  a 
prolific  source.  Usually  as  the  result  of 
injury  the  synovial  fringes  may  become 
inflamed,  condensed,  and  finally  sep- 
arated, leaving  the  detached  body  float- 
ing free  in  the  joint.  This  is  shown  to 
be  the  case  by  some  foreign  bodies'  being 
covered  with  synovial  membrane.  They 
are  not  only  fibrinous  in  character,  but 
also  cartilaginous.  Cartilage-cells  are 
normally  found  in  the  synovial  fringes, 
and  it  is  easy  to  see  how  an  injury  could 
start  up  sufficient  action  to  form  an  ap- 
preciable lump.  Sometimes  the  bodies 
are  found  with  a  pedicle,  by  which  they 
are  still  attached  to  the  synovial  fringes. 
Some  of  the  cartilages  may  be  so  severely 
injured  as  to  be  partially  or  wholly  de- 
tached or  torn  off.  The  fragment  then 
floats  free  in  the  joint  or  if  only  partially 
detached  becomes  parted  later  on. 

Riziform  (melon -seed)  bodies  in  ten- 
don-sheaths and  joints  are  not  composed 
of  ordinary  fibrin,  and  cannot  be  con- 
sidered in  any  case  to  be  produced  by 
coagulation  of  the  fluid  contents  of  the 
sac  or  joint.  They  are  rather  products 
of  coagulation-necroses  of  the  internal 
wall  of  the  sheath  or  sac.  Schuchardt 
(Virchow's  Arehiv,  Oct.  2.  '88). 

Affection  of  knee-joint  simulating  dis- 
location of  semilunar  cartilage.  Growth 


attached  to  synovial  membrane  lining 
capsule,  easily  removed,  derived  from 
synovial  fringes.  C.  Byron  Turner  (Brit. 
Med.  Jour.,  Oct.  13,  '94). 

Literature  of  '96-'97-'98. 

Rare  variety  of  loose  cartilage  removed 
from  the  knee-joint;  it  consisted  of  a 
hard,  lipomatous  mass  affecting  the  syno- 
vial membrane;  there  were  also  many 
smaller  similar  masses.  B,.  C.  Chicken 
(Brit.  Med.  Jour.,  Jan.  1,  '98). 

The  semilunar  cartilages  are  particu- 
larly liable  to  be  the  seat  of  injuries. 
Sometimes  a  piece  of  bone  is  detached 
along  with  the  cartilage,  as  occurred  in  a 

;  patient  of  mine.  These  bodies  not  in- 
frequently contain  calcareous  or  true 
bony  matter.    In  osteoarthritis  or  ar- 

|  thritis  deformans  loose  bodies  are  fre- 
quent and  may  exist  in  great  numbers. 
This  is  only  what  would  be  expected  of 
a  disease  in  which  the  various  cartilag- 
inous and  fibrous  structures  are  so  ex- 
tensively affected. 

There  is  usually  a  clear  history  of  in- 
juries in  these  cases,  to  which  the  origin 
of  the  trouble  can  be  traced. 

Literature  of  '96-'97-'98. 

The  literature  from  1883  to  1893  shows 
that,  of  143  cases  of  floating  bodies  in 
the  joints  in  which  an  operation  had  been 
performed,  83  (in  78  of  which  the  knee 
was  the  joint  affected)  were  of  trau- 
matic, 39  of  pathological,  and  19  of  un- 
known origin.  The  injuries  which  may 
cause  the  formation  of  floating  bodies  are 
forced  movements,  either  in  normal 
curves  or — which  is  probably  nunc  fre- 
quent— in  an  abnormal  direction:  and 
external  forces  acting  upon  the  articular 
surfaces  or  their  cartilaginous  margins. 
In  some  cases  forms  co-operate.  Max 
Schiiller  (Centralb.  f.  Chir..  Feb.  29,  '96). 

Treatment. — In  loose  bodies  traceable 
to  injury  removal  is,  if  possible,  indicated 
at  once.    The  procedure  which  I  have 
found  most  satisfactory  is  as  follows: 
'  The  Burgeon  feels  for  the  loose  body,  and 


JOINTS,  LOOSE  BODIES  IN.  TREATMENT. 


285 


when  found  crowds  it  into  some  corner 
and  holds  it  firmly  there  with  his  thumb. 
Still  keeping  np  the  pressure  the  patient 
is  etherized  and  an  incision  made  with 
the  other  hand  down  to  the  capsule  of 
the  joint  directly  over  the  loose  body. 
A  pin  is  then  thrust  into  it  and  an  in- 
cision made  directly  through  the  capsule 
and  the  body  turned  out.  Special  sutur- 
ing of  the  capsule  is  not  necessary;  two 
or  three  deep  interrupted  sutures  to 
close  the  wound  is  all  that  is  necessary. 
If  pressure  is  relaxed  before  the  pin  is 
thrust  into  the  loose  body,  it  may  slip  j 
away  into  the  joint  and  be  lost.    They  j 


arthritis  they  are  apt  to  be  so  numerous 
as  to  preclude  the  giving  of  relief  by  an 
operation  for  removal. 

Analysis  of  105  cases  of  floating  car- 
tilages in  which  antiseptic  operations 
have  been  performed,  with  but  1  death. 
Woodward  (Boston  Med.  and  Surg.  Jour., 
Apr.  25,  '89). 

Absence  of  danger  in  free  incisions  into 
joints  made  under  aseptic  precautions 
emphasized,  in  order  to  remove  loose 
bodies  which  are  firmly  wedged  between 
the  articular  surfaces,  without  injury  to 
the  joint.  A  limited  or  external  longi- 
tudinal incision  is  made,  the  leg  is  bent 
inward  or  outward,  so  as  to  separate  the 
joint-surfaces  sufficiently  to  remove  the 


Loose  bodies  in  the  knee-joint.  {Schiiller.) 


cannot  be  made  to  appear  at  will.  The 
favorite  places  for  them  are  on  each  side 
of  the  patella,  especially  the  outer  side 
and  down  below  and  to  its  inner  side. 
In  cases  which  will  not  submit  to  opera- 
tion, some  device  may  be  utilized  to 
alleviate  the  affliction.  A  simple  elastic 
knee-cap  may  afford  some  relief.  Some- 
times the  body  only  causes  trouble  when 
either  excessive  flexion  or  longitudinal 
rotation  of  the  bones  of  joint  takes  place; 
when  this  is  so  dressings  or  apparatus 
that  limit  flexion  and  to  a  great  extent 
prevent  rotation  may  be  applied.  When 
the  loose  bodies  are  the  result  of  osteo- 


body  (see  figure).  If  not  carried  too  far, 
this  bending  does  not  injure  the  liga- 
ments. Schiiller  (Deut.  med.  Woch., 
Aug.  7,  '90). 

Ten  hundred  and  forty- seven  loose 
bodies  removed  from  a  single  knee-joint 
of  a  man  of  22  years.  James  Berry  (Brit. 
Med.  Jour.,  May  19,  '94). 

Literature  of  '96-'97-'98. 

The  formation  of  floating  bodies  may 
be  prevented  by  immobilization  of  the 
joint.  When  floating  bodies  have  been 
formed,  their  removal  by  operation  is 
strictly  to  be  insisted  upon,  the  more  so 
and  the  sooner  because  the  disturbance 
which  they  cause  increases  with  time. 


286 


JOINTS.  ANKYLOSIS. 


Max  Schiiller  (Aerztlichen  Sachver.  Zeit.; 
N.  Y.  Med.  Jour.,  Apr.  4,  '96). 

In  foreign  bodies  in  the  joints,  treat- 
ment may  consist  of  wearing  an  appara- 
tus (such  as  Marsh's,  for  prevention  of 
semilunar-cartilage  dislocation)  to  pre- 
vent full  movement  of  the  joint,  and  thus 
avoid  the  painful  locking  and  injury  to 
the  synovial  membrane,  or,  what  is  in- 
comparably superior  when  perfect  asep- 
sis can  be  obtained,  operation  may  be 
performed.  In  locating  the  body  the 
local  anaesthesia  of  Schleich  is  of  the 
greatest  value,  as  the  active  co-operation 
of  the  patient  is  frequently  essential. 
Attempts  to  fix  the  body  by  a  pin  before 
anaesthesia  often  prove  unsuccessful,  but 
if  the  body  can  be  coaxed  to  one  side  of 
the  joint  and,  while  it  is  held  in  in  its 
superficial  position,  the  articulation  is 
flexed  and  held  in  that  position  by  a 
bandage  at  a  lower  and  upper  point  upon 
the  limb,  the  body  will  not  only  often 
remain  rigidly  in  position,  but  will  shoot 
out  as  a  pea  from  a  pod  when  the  over- 
lying capsule  is  incised.  T.  S.  K.  Morton 
(Phila.  Polyclinic,  Jan.  25,  '96). 

Evidence  to  the  effect  that  where 
multiple  foreign  bodies  have  been  treated 
by  operation  there  has  been  more  or  less 
limitation  of  motion,  whereas  in  the  cases 
in  which  there  is  only  one  body  the  re- 
sults have  been  excellent.  James  P. 
Tuttle  (Med.  Record,  Apr.  25,  '96). 

Analysis  of  cases  of  floating  cartilage 
of  the  knee  treated  by  operation  between 
1885  and  1895.  The  total  number  of 
cases  considered  to  have  been  reported  in 
sufficient  detail  to  warrant  attention  was 
72.  Of  these  23  were  pedunculated  and 
49  non-pedunculated.  Besides  bodies  de- 
tached by  slight  injury,  portions  might 
be  chipped  off  from  the  ends  of  the  bones 
as  a  result  of  severe  injuries. 

The  majority  of  the  cases  were  ex- 
amples of  bodies  detached  by  a  process 
the  nature  of  which  is  as  yet  unknown. 
In  1860  the  cases  occurring  up  to  that 
time  had  been  collected.  Of  the  one  hun- 
dred and  thirty-five  that  had  been  oper- 
ated upon  by  direct  incision,  there  were 
74.8  per  cent,  of  successes.  21.4  per  cent, 
of  deaths,  and  3.8  per  cent,  of  failures. 
Muller,  in  1SS6.  had  collected  one  hun- 
dred cases  with  ninety-six  recoveries  and 


four  deaths.  Between  1885  and  1895  no 
fatal  results  recorded.  Sixty-seven  cases 
tabulated  with  reference  to  the  function 
of  the  joint  after  operation.  It  had  been 
found  that  in  22  per  cent,  there  had  been 
some  disability,  in  13  per  cent,  more  or 
less  limitation  of  motion,  and  in  4  per 
cent,  ankylosis. 

Sixty-two  out  of  the  72  cases  analyzed 
in  this  paper  made  a  complete  recovery; 
in  16  per  cent,  more  or  less  disability  was 
acknowledged.  Of  the  10  unfavorable 
results  6  occurred  after  the  removal  of 
pedunculated  bodies,  and  4  after  opera- 
tions for  the  removal  of  non-pedunculated 
bodies.  Of  the  6  unfavorable  results  3 
were  unavoidable  from  the  operative  pro- 
cedures required,  and  3  were  due  to  dis- 
ease existing  prior  to  operation  and  per- 
sisting after  it.  P.  R.  Bolton  (Med.  Rec, 
Apr.  25,  '96). 

In  operations  for  loose  cartilages  in  the 
knee-joint  their  removal  preferred  to 
suture.  In  all  of  the  twelve  cases  person- 
ally operated  upon  the  functional  result 
has  been  perfect  and  the  recovery  afe- 
brile. Marsh  (Brit.  Med.  Jour.,  Mar.  5, 
'98). 

Ankylosis. 

When  from  injury  or  disease  a  joint 
loses  its  function  and  becomes  stiff,  it  is 
said  to  be  ankylosed.  Ankylosis  may  be 
either  bony  or  fibrous.  The  former  has 
been  called  true  and  the  latter  false 
ankylosis.  In  bony  ankylosis  the  bones 
entering  into  the  formation  of  the  joint 
have  becomeamited  by  bony  tissue.  In 
fibrous  ankylosis  either  the  articular  ends 
of  the  bones  are  united  by  fibrous  bands 
going  directly  from  one  to  the  other  or 
else  motion  is  restricted  by  changes  in 
and  around  the  capsule  of  the  joint. 
The  name  is  not  applied  to  loss  of  motion 
due  to  changes  in  structures  unconnected 
with  the  joint,  such  as  contracted  ten- 
dons or  muscles  or  cicatrices  from  burns. 
All  inflammations  of  joints  from  what- 
ever cause,  if  violent  enough  and  long 
continued,  are  liable  to  cause  ankylosis. 
Such  affections  as  destroy  the  articular 


JOINTS.    ANKYLOSIS.  TREATMENT. 


287 


surfaces  of  the  joint  are  very  liable  to  I 
be  followed  by  ankylosis.  Suppuration  ! 
oftentimes,  but  not  always,  results  in  a 
more  or  less  complete  loss  of  motion. 
Serious  joint  disease  almost  always  re- 
sults in  some  loss  of  movement  of  the 
joint,  but  a  certain  slight  amount  may 
remain;  hence  one  speaks  of  restricted 
motion  or  one  may  perhaps  be  allowed 
to  use  the  term  "incomplete  ankylosis" 
to  express  this  condition. 

The  question  of  ankylosis  is  determined 
by  the  severity  of  the  inflammation,  the 
duration  of  the  inflammation,  the  pres- 
ence of  intra-articular  pressure,  the  sub- 
sequent cicatricial  contraction  of  soft 
parts  around  the  joint,  the  tissues  in- 
volved, and  the  amount  of  destruction 
of  bone  and  cartilage.  Inflamed  joints 
treated  upon  the  plan  of  absolute  immo- 
bilization and  the  relief  of  intra-articu- 
lar pressure  furnish  by  far  fewer  cases  of 
ankylosis,  limited  motion,  and  deformity. 
Phelps  (N.  Y.  Med.  Jour.,  May  17,  '90). 

To  diagnose  ankylosis  one  must  ex- 
clude the  rigidity  caused  by  muscular 
contraction;  therefore  in  doubtful  cases 
the  examination  should  be  made  under 
an  anaesthetic.  The  production  of  pain 
by  attempted  motion  is  good  evidence 
that  complete  ankylosis  is  not  present, 
because  it  is  the  movement  of  the  parts 
that  causes  the  pain.  An  approximate 
idea  of  the  extent  of  the  stiffness  may 
be  obtained  from  the  clinical  history  of 
the  case  as  to  whether  the  disease  has 
been  violent  in  character  and  long  in 
duration. 

Treatment.  —  This  is  preventive  and 
curative.  The  attempt  to  prevent  the 
occurrence  of  ankylosis  in  joints  that  are 
the  subject  of  disease  by  means  of  passive 
motion  are  usually  not  only  futile,  but 
positively  harmful.  Any  violent  or  ex- 
tensive movements  only  increase  the  in- 
flammation and  activity  of  the  disease 
already  present.  The  joint  has  enough 
to  do  to  attend  to  the  original  disease 


without  having  to  contend  with  the 
added  violence  of  misapplied  surgical 
energy.  The  amount  of  pain  experi- 
enced is  a  good  guide  to  the  amount  of 
motion  to  be  practiced,  if  it  is  severe  or 
long  continued  it  is  evidence  that  the 
movements  have  been  too  extensive.  It 
is  best  to  wait  until  the  active  evidences 
of  disease  have  disappeared  before  at- 
tempting movements.  In  tuberculous 
and  other  diseases  the  attempt  to  restore 
motion  is  apt  to  relight  the  original 
trouble;  therefore  it  is  well  to  have  as 
long  an  interval  intervene  as  possible. 
Restoration  of  motion  is  only  possible 
in  cases  of  fibrous  ankylosis,  not  bony, 
and  when  the  disease  has  not  been  too 
extensive.  The  utmost  that  can  be 
hoped  for  in  many  cases  is  the  placing 
of  the  limb  in  a  more  useful  position. 
When  it  is  desired  to  restore  motion  in 
a  stiff  joint,  the  patient  should  be  anaes- 
thetized and  the  joint  first  flexed  and 
then  extended;  this  should  be  repeated 
until  as  much  motion  as  possible  has 
been  secured.  The  part  is  then  kept  at 
rest  and  ice-bags  applied  until  the  re- 
sultant inflammation  has  subsided,  then 
mild  passive  motion  is  to  be  employed 
for  some  time  until  it  is  seen  whether 
anything  has  been  gained.  If  not,  then 
it  is  useless  to  repeat  the  procedure,  for 
if  no  motion  has  been  gained  some  will 
probably  have  been  lost,  and  with  each 
succeeding  effort  the  condition  of  the 
joint  is  worse.  Care  must  be  taken  not 
to  fracture  the  bones  in  making  the 
necessary  manipulations.  The  bones 
from  long-continued  disease  are  apt  to 
be  somewhat  atrophied  and  not  so  strong 
as  they  normally  are.  If  it  is  desired  to 
increase  the  extension  of  a  joint,  a  good 
plan  is  to  apply  some  sort  of  a  splint  or 
apparatus  that  holds  the  part  in  its  most 
extended  position  and  then  remove  it 
daily  and  apply  passive  motion  and  again 


288 


JOINTS.    ANKYLOSIS.  THE. 


1ATMENT. 


JUNIPER. 


replacing  the  apparatus.  An  apparatus 
producing  gradual  pressure,  such  as  the 
Strohmeyer  screw,  is  often  serviceable 
when  it  can  be  applied. 

Case  in  which,  as  the  result  of  forcible 
breaking  up  of  ankylosis  at  the  knee, 
there  occurred  gangrene,  necessitating 
amputation  through  the  thigh.  Stavely 
(Med.  Record,  Oct.  20,  '88). 

Case  of  fatal  fat-embolism  after  for- 
cible straightening  of  both  knee-joints. 
Ahrens  (Beitriige  zur  klin.  Chir.,  B.  14, 
H.  1,  '95). 

Stiffness  arising  from  injuries  such  as 
fractures  are  usually  due  to  their  involv- 
ing the  joint  and  from  misplacement  of 
the  fragments  directly  interfering  with 
motion  or  else  to  pouring  out  of  callus 
and  non-bony  effusion  from  the  injured 
parts.  Ankylosis  from  the  former  is  to 
be  prevented  by  a  more  correct  apposi- 
tion of  the  fragments  before  they  have 
had  time  to  become  fixed  in  their  ab- 
normal position.  Ankylosis  from  the 
latter  is  to  be  avoided  by  gentle  and  per- 
sistent passive  motion. 

In  fibrous  ankylosis,  electrolysis:  con- 
tinuous current  passed  directly  through 
the  joint,  with  the  negative  pole  nearest 
the  adhesions,  amount  given  ranging 
from  40  to  150  milliamperes.  F.  W. 
Gwyer  (N.  Y.  Med.  Jour.,  June  8,  15, 
'05). 

Bony  ankylosis  is  to  be  treated  either 
with  a  view  of  bettering  the  position  of 
the  part  or  to  the  formation  of  a  false 
joint.  If  the  former  is  aimed  at,  then 
osteotomy  is  of  service,  especially  in 
cases  of  hip  disease  in  which  the  neck 
of  the  femur  is  divided  or  a  subtro- 
chanteric osteotomy  performed;  also  to 
remedy  a  bad  position  of  the  foot.  In 
the  knee  the  amount  of  deformity  is  usu- 
ally so  great  as  to  require  resection;  here 
osteotomy  is  not  applicable. 

Case  of  excision  of  both  knees  for 
angular  ankylosis.  NTewbolt  (Lancet, 
Nov.  24,  '95). 


In  the  shoulder- joint  ankylosis  is  not 
so  disabling  as  in  other  joints,  and  usu- 
ally no  operation  is  advisable.  If,  how- 
ever, motion  is  desired,  it  can  be  ob- 
tained by  resection  of  the  head  of  the 
bone.  In  the  elbow-joint  good  results 
are  obtained  by  a  resection  of  the  joint; 
good  and  serviceable  motion  is  often  ob- 
tained. When  too  little  motion  results, 
it  is  usually  because  too  little  bone  has 
been  removed.  As  healing  progresses, 
what  at  first  looks  like  a  flail- joint  be- 
comes a  very  serviceable  one.  Ankylosis 
of  the  spine  has  been  treated  by  forcible 
straightening  of  the  kyphosis  by  non- 
operative  means,  but  its  true  value  as 
yet  is  undetermined.  In  some  cases  new 
bone  has  not  formed  to  fill  up  the  re- 
sultant gap,  and  consequently  relapses 
are  very  liable  to  occur.  Straightening 
in  several  sittings  is  better  than  to  com- 
pletely straighten  at  one.  The  articula- 
tion of  the  lower  jaw  becomes  ankylosed 
at  times,  and  is  to  be  treated  by  liberal 
resection  of  bone,  preferably  done  from 
within  the  mouth.  The  treatment  of 
ankylosis  of  the  finger-joints  depends  on 
the  occupation  of  the  individual.  In 
people  who  have  manual  work  to  do,  as 
machinists,  carpenters,  etc.,  a  stiff  finger 
is  so  much  in  the  way  and  so  often  be- 
comes injured  that  it  is  sometimes  ad- 
visable to  amputate  it.  The  patient, 
i  however,  should  be  the  one  to  decide  as 
to  the  advisability  of  amputation,  and  it 
is  best  to  wait  until  by  trial  he  finds  the 
affected  finger  useless. 

GrWiLYM  G.  Davis, 

Philadelphia. 

JUNIPER. — Juniper  is  the  fruit  or 

berries  of  the  Juniper  us  communis,  of 
the  family  Conifercr.  an  evergreen  of 
Northern  Europe  and  America.  The 
berries  contain  2  to  2  l/2  per  cent,  of 
a  volatile  oil,  upon  which  its  medicinal 


JUNIPEE.  POISONING. 


289 


effects  chiefly  depend,  a  non-crystalliz- 
able  principle  (juniperin),  and  from  15 
to  30  per  cent,  of  sugar,  etc.  The  vola- 
tile oil  also  exists  in  the  leaves  and  other 
parts  of  the  plant,  and  by  first  bruising 
and  then  macerating  them  in  alcohol  or 
spirit  the  liquor  commonly  known  as 
gin  is  produced.  The  oil  of  juniper  ob- 
tained from  the  wood  is  inferior  to  that 
distilled  from  the  berries,  which  is  the 
official  form  of  oil  from  which  the  spirit 
and  compound  spirit  are  made.  The 
compound  spirit  is  the  pharmacopceial 
substitute  for  gin  and  is  to  be  preferred 
to  the  latter,  which  is  frequently  adul- 
terated with  oil  of  turpentine. 

The  oil  of  cade  (oleum  cadinum, 
U.  S.  P.),  obtained  by  destructive  dis- 
tillation from  the  wood  of  Juniperus 
oxycedrus,  is  a  thick,  black,  empyreu- 
matic  oil  resembling  and  having  the  odor 
of  tar,  and  having  an  acrid  disagreeable 
taste.  It  is  soluble  in  ether,  chloroform, 
and  carbon  disulphide. 

Literature  of  '96-'97-'98. 

Juniper-tar  (=  oil  of  cade)  contains 
(1)  hydrocarbons  (boiling-point,  210°  to 
400°  C),  which  form  its  greater  part;  (2) 
acetic  acid  and  its  homologues;  (3)  phe- 
nols and  allied  bodies;  and  (4)  resinous 
substances,  which  form  the  residuum 
after  distillation,  (a)  The  chief  differ- 
ence between  the  phenols  of  coniferous 
trees  (pine  and  juniper)  and  others 
(beech,  birch,  aspen,  etc.)  is  that  the  lat- 
ter contain  diphenols  and  bodies  derived 
from  triphenols  (pyrogallol) ,  with  small 
quantities  of  monophenols,  while  the  for- 
mer contain  only  diphenols,  chiefly  de- 
rivatives of  pyrocatechin  (guaiacol  and 
its  homologues,  methyl-  [=  creosol] 
ethyl-  and  propyl-  guaiacol).  (h)  Juni- 
per-tar is  poorer  in  phenols  than  thai  of 
pine  or  aspen,  (c)  It  is  less  acid  and  has 
less  disinfecting  power  than  the  other 
tars,  (d)  As  a  5-per-cent.  mixture  with 
water  ils  disinfecting  action  is  almost 
nil.  (e)  An  alkaline  solution  (5-per-cent. 
tar  in  1-per-cent.  KOTI  solution)  has  a 

4 


marked  disinfecting  action,  killing  a  two- 
day-old  culture  of  intestinal  bacteria 
from  a  body  dead  of  cholera  when  mixed 
with  it  in  equal  parts  in  20  to  30  minutes, 
a  culture  of  typhoid  bacilli  in  2,  and  of 
B.  pyocyaneus  in  10  minutes.  Still  this 
action  is  inferior  to  that  of  an  alkaline 
solution  of  pine-,  birch-,  or  aspen-  tar. 
if)  Anthrax-spores  are  killed  by  pure 
juniper-tar  in  7  to  9  days,  by  its  5-per- 
cent, alkaline  solution  in  24  hours.  (<j) 
The  alkaline  solution  has  but  a  feeble 
action  on  pure  cultures  of  tubercle  bacilli, 
and  does  not  kill  them  after  24  hours, 
for  all  guinea-pigs  inoculated  with  these 
insufficiently  -  sterilized  cultures  died 
about  the  60th  day.  (h)  Juniper-tar  is 
9  times  as  expensive  as  pine,  and  4  V2 
times  as  birch.  Witold  de  Schulz  (Arch, 
des  Sci.  Biol,  de  lTnstitut.  Imper.  de 
Med.  Exper.  a  St.  Petersbourg,  Tome  v, 
Nos.  4,  5,  '97). 

Preparations  and  Doses. — Oleum  juni- 
peri,  1  to  15  minims. 

Spiritus  juniperi,  1/4  to  1  drachm. 

Spiritus  juniperis  compositus,  1  to  T 
drachms. 

Physiological  Action. — The  diuretic 
action  of  juniper  is  due  to  a  stimulating- 
effect  upon  the  renal  structures,  which 
may  reach  irritation  when  the  drug  is 
administered  in  excessive  doses.  Anuria 
may  thus  be  induced.  These  effects  are 
produced  by  the  volatile  oil,  which,  first 
absorbed  into  the  general  system,  is  then 
eliminated  through  the  kidneys.  It  also 
has  a  stimulating  action  upon  the  gastro- 
intestinal tract. 

Poisoning  by  Juniper.  —  Juniper  in 
overdose  produces  an  irritant  action  on 
the  gastro-intestinal  canal  and  upon  the 
genito-urinary  tract.  Its  action  upon 
the  kidneys  may  cause  strangury,  pria- 
pism, hamiaturia,  suppression,  and  uraB- 
mic  intoxication.  A  violet-like  odor 
may  be  detected  in  the  urine.  A  rash 
like  that  following  the  use  of  copaiba  is 
sometimes  noticed. 

Treatment   of   Poisoning.  —  Tf  seen 

19 


290  KERATITIS.  SYMPTOMS. 


early,  the  stomach  should  be  washed 
out  with  a  stomach-siphon,  and  diluent 
and  dimulcent  drinks  used  freely.  An 
enema  of  laudanum  or  the  use  of  mor- 
phine by  hypodermic  injection  will  re- 
lieve the  poisonous  effects,  while  stimu- 
lants will  avert  collapse. 

Therapeutics. — Genito-Urikary  Dis- 
orders.— As'  a  stimulant  to  the  genito- 
urinary tract  juniper  has  long  been  con- 
sidered valuable.  It  is  especially  indi- 
cated in  chronic  disorders,  as  chronic 
nephritis,  chronic  pyelitis,  and  chronic 
catarrhal  inflammation  of  the  bladder. 
Active  acute  inflammation  contra-indi- 
cates  its  use.  In  the  later  stage  of  scar- 
latinal nephritis,  when  reaction  has  set 
in  and  the  renal  secretory  apparatus  is 
in  an  atonic  condition,  it  is  of  great 
service.  It  is  a  very  satisfactory  remedy 
in  various  forms  of  dropsy.  An  infusion 
of  the  berries  (1  ounce  to  the  pint  of 
boiling  water)  with  the  addition  of  1/2 
ounce  of  cream  of  tartar  may  be  taken 
daily,  with  benefit  in  chronic  Bright's 
disease;  it  relieves  markedly  the  oedema 
and  effusions  incident  to  that  disorder. 


Juniper-berries  tried  in  a  case  of  renal 
dropsy  with  good  results.  Goldschmid 
(Cones,  f.  Schweizer  Aerzte,  Dec.  1, 
'88). 

As  a  diuretic  for  young  children,  2  to 
3  teaspoonfuls  of  the  juice  of  the  common 
juniper-berries  are  highly  recommended. 
Yogel  (Annual,  *<J0). 

Juniper  gives  relief  in  passive  con- 
gestion of  the  kidneys  and  the  lumbar 
pain,  or  sensation  of  weight  across  the 
lumbar  region,  so  frequently  experienced 
by  aged  persons,  especially  if  the  kidneys 
are  inactive.  Prostatorrhcea  and  gleet 
are  generally  benefited  by  juniper  in 
I  moderate  doses. 

G  A  STR O-lNTESTIXAL  DISORDERS.   

Juniper  is  a  valuable  stomachic.  In 
small  doses  it  increases  the  appetite  and 
aids  digestion.  A  few  drops  of  the  com- 
pound spirit  in  hot  water  will  relieve 
the  flatulence  and  pain  of  infantile  colic. 
Gin  is  a  favorite  domestic  remedy  for 
pain  associated  with  menstrual  disorders. 
A  few  teaspoonfuls  in  hot  water  com- 
bined with  external  applications  of  heat 
generally  gives  prompt  relief. 


K 


KERATITIS.  —  Gr.,  yjpag,  cornea, 
and    iTtg,  inflammation. 

Definition. — Inflammation  of  the  cor- 
nea. 

Varieties. — The  varieties  of  keratitis 
are  interstitial,  neuropathic,  malarial, 
dendritic,  herpetic,  punctate,  phlyctenu- 
lar, bullous,  pannous,  traumatic,  striate, 
suppurative,  and  xerotic  keratitis. 

Symptoms. — The  most  constant  symp- 
tom is  opacity;  and  this  may  be  the  only 
objective  symptom  present.  It  may  vary 
from  the  slightest  increase  of  the  hazi- 
ness that  is  visible  in  the  normal  cornea, 
tinder  strong  oblique  illumination,  with 
a  good  magnifier,  to  complete  opacity 


through  which  no  trace  of  the  iris  or 
pupil  is  visible.  The  opacity  always 
causes  impairment  of  vision,  propor- 
tioned to  the  extent  to  which  it  invades 
the  part  of  the  cornea  in  front  of  the 
pupil. 

Redness  is  manifest,  not  usually  in 
the  cornea  itself,  but  in  the  vessels  at 
its  border,  which  supply  it  with  nutrient 
fluid;  and  the  enlargement  of  which 
gives  rise  to  the  pericorneal  zone.  In 
chronic  keratitis,  however,  as  during  the 
later  stages  of  corneal  ulcer,  and  in 
pannus,  trunks  of  considerable  size1  may 
he  seen  arising  from  the  vessels  at  the 
corneal  margin  extending  on  the  cornea. 


KERATITIS. 

and  dividing,  to  be  distributed  to  the  1 
superficial  corneal  layers.  In  interstitial 
keratitis  great  numbers  of  extremely- 
small  vascular  loops  extend  from  the 
margin  into  the  deep  corneal  tissue.  As  I 
the  inflammation  goes  on  to  resolution, 
the  corneal  vessels  atrophy  and  in  most 
cases  entirely  disappear. 

The  pain  of  keratitis  is  usually  severe. 
It  may  be  that  of  a  foreign  body  in  the 
eye,  a  smarting,  burning,  or  severe  ach- 
ing pain.  It  is  commonly  attended  with 
photophobia,  which  may  become  intense, 
and  with  increased  lacry  matron.  Swell- 
ing may  occur  in  corneal  inflammation, 
but  it  is  inconstant  and  of  little  conse- 
quence. 

Loss  of  substance,  ulceration,  is  a  far 
more  important  symptom.  In  many 
forms  of  inflammation  the  resulting  ulcer 
is  the  most  significant  and  most  serious 
symptom.  Its  characteristics  are  closely 
identified  with  the  variety  of  keratitis, 
and  will  therefore  be  considered  under 
the  special  symptoms  peculiar  to  each 
variety.  In  all  corneal  ulcers,  however, 
extension  usually  occurs  by  the  breaking 
down  of  an  infiltrated  area;  and,  while 
active,  the  surface  of  the  ulcer,  when 
wiped  willi  a  pledget  of  cotton,  lacks  the 
smooth  reflex  of  the  normal  corneal  sur- 
face. Before  the  ulcer  begins  to  heal 
the  points  of  infill  ration  disappear  and 
the  ulcer  is  said  to  be  "clean."  Its  sur- 
face, too,  becomes  coated  with  epithe- 
lium, and,  although  not  so  even  as  the 
norma]  corneal  surface,  appears  to  have 
the  same  polish.  As  the  loss  of  sub- 
stance is  made  good  with  new-formed 
tissue,  the  lack  of  transparency  in  the 
scar-tissue  gives  rise  to  an  opacity,  which 
will  be  most  noticeable  some  weeks  after 
nil  sinus  of  active  inflammation  have 
ceased.  Such  corneal  opacity,  and  the 
possibility  of  perforation  of  the  cornea, 


SYMPTOMS.  291 

and  its  sequels  (see  Cornea,  volume  ii) 
are  the  special  dangers  of  ulcerative 
keratitis. 

Interstitial  keratitis  begins  with 
photophobia,  slight  redness,  and  irrita- 
bility of  the  eye.  Opacity  appears  faintly 
near  the  middle  of  the  cornea,  involving 
the  deeper  layers,  and  increases  from  day 
to  day,  and  extends  toward  the  periph- 
ery. Then  at  the  border,  usually  the 
upper  or  lower  border,  the  cornea  be- 
comes opaque,  and  fine  loops  of  deep 
vessels  push  out  in  it,  and  extend  gradu- 
ally farther  toward  the  centre,  giving  the 
tissue  they  invade  a  characteristic  "sal- 
mon'' color.  Iritis  or  choroidal  inflam- 
mation is  liable  to  attend  this  form  of 
keratitis,  and  may  be  manifest  before  the 
opacity  of  the  cornea  wholly  hides  the 
iris  and  pupil.  Usually  both  eyes  are 
affected.  The  course  of  this  form  of 
keratitis  is  essentially  chronic,  usually 
running  through  several  months,  and 
sometimes  years  before  it  subsides.  The 
corneal  surface  often  becomes  quite  un- 
even; but  is  rarely  ulcerated.  The  dis- 
ease generally  affects  both  eyes;  and  usu- 
ally occurs  during  childhood  or  youth, 
but  may  be  met  in  early  adult  life,  or 
even  later.  The  patient  frequently  pre- 
sents other  evidences  of  inherited  syph- 
ilis, particularly  the  Hutchinson  teeth, 
or  the  nasal  deformity;  or  the  symptoms 
may  be  those  that  are  grouped  under  the 
term  scrofula. 

Three  cases  of  late  hereditary-syphilitic 
keratitis,  appearing,  respectively,  at  the 
ages  of  20,  52,  and  2!)  years.  The  eases 
were  characteristic  and  gave  additional 
proof  of  the  fact  that  the  absorption  of 
the  exudates  in  the  cornea  takes  place 
all  the  more  slowly  and  incompletely,  the 
older  the  patients.  In  one  instance  the 
sclerosis  Avas  present  five  years  after  the 
beginning  of  the  attack.  A.  Chevallereau 
(Jour,  des  Mai.  Cut.  et  Syph.,  Sept., 
'95). 


292  KERATITIS.  SYMPTOMS. 


Literature  of  '96-'97-'98. 

Instance  of  conjunctival  interstitial 
keratitis  of  syphilitic  origin.  The  case 
was  seen  directly  after  birth.  The  lids 
were  swelled,  and  there  was  a  dirty- 
yellow  discharge  from  the  conjunctiva. 
The  cornese  were  dull  gray.  Barabasher 
(Vestnik  of  Ophthal.,  May-June,  '96). 

A  condition  of  keratitis  interstitialis 
annularis  in  an  eye  with  increased  ten- 
sion and  intense  congestion.  Vision 
equaled  ability  to  see  to  count  fingers 
at  four  feet.  There  was  a  ring  of  deep 
and  dense  opacity  between  one  and  two 
millimetres  in  width,  entirely  surround- 
ing the  central  two-thirds  of  the  corneal 
area.  The  patient,  a  man  67  years  of 
age,  was  suffering  from  hay  fever.  The 
acute  symptoms  quickly  subsided  under 
treatment,  but  the  opacity  persisted  for 
about  two  months.  Moulton  (Annals  of 
O.,  0.,  and  L.,  July,  '96). 

Neuropathic  keratitis,  or  neuro- 
paralytic keratitis,  is  usually  marked  by 
diminished  sensitiveness  of  the  cornea 
to  touch  as  compared  with  the  sound  eye. 
It  also  may  he  attended  with  iritis,  but 
is  commonly  confined  to  one  eye.  The 
liability  to  it  increases  with  age;  and 
there  is  likely  to  be  other  evidence  of 
involvement  of  the  ophthalmic  branch 
of  the  fifth  nerve,  as  herpes  zoster,  neu- 
ralgia, or  distinct  paralysis.  Curiously 
enough,  it  is  possible  to  remove  totally 
the  Gasserian  ganglion,  and  by  careful 
protection  of  the  eyes  during  the  first 
few  weeks,  to  escape  any  neuropathic 
keratitis.  There  is  very  likely  to  be 
ulceration,  although  this  may  not  occur; 
and  the  ulcer  may  become  infected  and 
the  keratitis  loose  its  characteristic  feat- 
ures. Its  course  is  quite  chronic;  but 
healing,  usually  with  more  or  less  opac- 
ity, mostly  occurs  in  three  to  six  months. 

Literature  of  '96-'97-'98. 

Physiological  experiments  on  monkeys 
demonstrate  that  the  Gasserian  ganglion 
has  no  trophic  influence  on  the  cornea, 
and  also  that  the  ophthalmic  of  (lie  fifth 


nerve  may  be  divided  and  the  ganglion 
extirpated  without  risking  the  destruc- 
tion of  the  eye.  Turner  (Abst.  Rec. 
d'Ophtal.,  Mar.,  '96). 

Malarial  K e  r  a  ti  t  i  s  . — Keratitis 
quite  neuropathic  in  its  clinical  charac- 
ter may  arise  in  malarial  persons  in  con- 
nection with  fifth-nerve  lesions,  espe- 
cially malarial  neuralgia.  But  in  a  more 
L  specific  form,  as  in  a  linear  branching 
I  ulcer,  it  also  occurs  with  impaired  sensi- 
bility to  touch,  and  some  opacity  of  the 
affected  part  of  the  cornea. 

Case  of  malarial  keratitis  in  which  the 
inflammation  was  manifested  as  a  periph- 
eral annular  parenchymatous  infiltration 
separated  from  the  corneal  margin  by  a 
zone  of  clear  tissue.  The  opacity  con- 
sisted of  numerous  minute  points  joined 
by  fine,  grayish  lines  sometimes  so  closely 
packed  together,  however,  that  the  inter- 
vening striae  could  not  be  distinguished. 
Examination  of  the  blood  failed  to  show 
any  malarial  organism.  Tenderness  in 
the  supra-orbital  notch  was  marked. 
l)e  Schweinitz  (Phila.  Polyclinic,  July  6, 
'95). 

Dendritic  keratitis  is  a  rare  disease 
also  characterized  by  linear  branching 
ulcers,  which  tend  to  extend  by  the 
formation  of  new  branches.  These 
branches  are  usually  straight  lines  meet- 
ing each  other  at  definite  angles.  It 
may  be  acute,  with  severe  pain,  or 
chronic,  witli  hut  a  slight  irritation. 

Herpetic  keratitis  occurs  late  in  the 
acute  infectious  fevers  and  in  diseases  of 
the  air-passages.  Small  vesicles  form  on 
the  cornea  and  rupture,  giving  rise  to 
minute  ulcers. 

Punctate  Keratitis. — The  term  ker- 
atitis punctata  is  usually  applied  to  the 
small,  rounded  dots  of  opacity  which 
form  on  the  posterior  surface  of  the  cor- 
nea in  iritis  and  cylitis.    Isolated  dots 

I  of  denser  opacity  in  the  midst  of  a  some- 
what hazy  cornea  mark  a  chronic  disease 

:  of  probably  syphilitic  origin,  not  at- 


KERATITIS. 

tended  with  much  redness  or  photo- 
phobia. Another  form  called  superficial 
punctate  keratitis,  marked  by  dots  and 
lines  of  opacity  just  below  the  anterior 
epithelium  of  the  cornea,  is  attended 
with  a  good  deal  of  conjunctival  redness, 
pain,  and  lacrymation.  It  is  liable  to  re- 
lapse, and  may  last  for  months. 

Phlyctenular  keratitis  occurs 
commonly  in  young  children,  in  close 
association  with  phlyctenular  conjunc- 
tivitis. The  phlyctenule  containing  cells 
and  fluid  arises  on  the  surface  of  the 
cornea,  and  in  a  few  hours,  or  a  day  or 
two,  ruptures  and  gives  rise  to  a  small 
ulcer.  Later  a  few  branching  vessels 
forming  a  long  narrow  leash,  usually 
somewhat  in  a  direction  of  a  radius  of 
the  cornea,  may  make  their  way  out  from 
the  nearest  portion  of  the  limbns  to  the 
region  of  the  ulcer.  This  is  especially 
likely  to  occur  if  several  phlyctenules 
have  successively  arisen  on  the  same  part 
of  the  cornea.  The  condition  is  then 
spoken  of  as  superficial  vascular  or  fascic- 
ular keratitis.  The  ulcers  rarely  perfo- 
rate the  cornea,  but  may  do  so.  This 
form  is  particularly  liable  to  relapse. 
It  is  often  attended  by  the  most  severe 
and  obstinate  photophobia. 

Bullous  keratitis  is  marked  by  re- 
current attacks  of  severe  burning  pain 
followed  quickly  by  the  raising  up  of 
a  large  bleb  or  bulla  on  some  part  of 
the  cornea.  The  epithelium  forming  the 
anterior  wall  of  the  bleb  quickly  rupt- 
ures, leaving  loose  shreds  of  epithelium 
and  a  broad  abraded  surface,  which  in 
a  few  days  heals  over,  and  some  months 
may  pass  before  there  is  a  recurrence. 
Two  forms  of  the  disease  are  recognized: 
one  occurring  in  eyeballs  that  have  been 
the  seat  of  severe  inflammation  of  the 
uvea]  tract,  and  have  undergone  degen- 
erative changes;  and  the  other  due  to 
previous  wounds  of  the  cornea  causing 


SYMPTOMS.  293 

|  extensive  loss  of  the  corneal  surface  in 
an  otherwise-healthy  eye. 

Literature  of  '96-'97-'98. 

Primary  bullous  keratitis  arises  as  fol- 
lows: Some  variable  times  after  an  abra- 
sion of  the  cornea  by  the  finger-nail,  a 
twig,  or  such  object,  there  occurs  an  at- 
tack of  severe  pain  in  the  eye,  which  al- 
ways begins  in  the  morning  when  the  pa- 
tient wakes  up.  It  usually  lasts  a  few 
minutes,  ceasing  with  the  occurrence  of 
an  abundant  flow  of  tears.  These  at- 
tacks recur  with  varying  frequency. 
There  is  photophobia,  hypersemia,  oedema 
of  the  lids,  etc.  At  this  stage  there  is 
discovered  a  large  bulla  of  the  cornea, 
which  is  frequently  only  half-filled  with 
clear  fluid  and  can  be  displaced  on  move- 
ment of  the  lower  eyelid;  a  small  spot 
of  cornea  is  seen  to  be  dull,  and  the  bleb 
or  its  remains  can  be  picked  off  with 
forceps,  leaving  a  large,  denuded  surface 
with  uneven  margins  extending  to  one- 
fifth  or  even  as  much  as  one-half  of  the 
area  of  the  cornea.  After  three  days  or  a 
little  more,  the  denuded  surface  is  again 
covered,  but  may  break  down  soon  there- 
after, and  the  same  process  be  repeated 
many  times.  There  is  usually  several 
months'  delay  from  the  time  of  the  origi- 
nal accident  until  the  development  of  the 
bulla.  Edmund  Jensen  (Arch.  d'Ophtal., 
Apr.,  '98). 

Pannous  Keratitis. — Pannus  is  an 
inflammation  and  vascular  opacity  of  the 

|  cornea,  occurring  in  trachoma,  after  the 
palpebral  conjunctiva  has  been  severely 
affected.  The  portion  of  the  cornea  in- 
volved is  that  which  comes  habitually  in 
contact  with  the  lids;  most  frequently 
the  upper  part,  but  sometimes  also  the 
lower.  The  part  affected  is  somewhat 
thickened  with  an  irregular  surface,  and 
more  or  less  hazy.  It  is  usually  bounded 
by  a  horizontal  line  marking  the  habit- 
ual position  of  the  lid-margin.  Large 
branching  trunks  of  superficial  vessels 
pass  out  upon  the  cornea,  from  the  ves- 
sels of  the  limbns;  their  distribution  is 

i  sharply  limited  by  the  line  bounding  the 


294  KERATITIS. 

affected  area.  Ulceration  is  not  infre- 
quent, but  is  not  characteristic  of  this 
form  of  keratitis. 

Traumatic  Keratitis. — Injuries  to 
the  cornea  may  set  up  a  general  inflam- 
mation of  the  membrane;  but  more  fre- 
quently they  cause  loss  of  substance  of 
the  cornea,  and  thus  originate  corneal 
ulcers.  If  small  and  not  affected,  such 
ulcers  heal  quickly,  with  little  pain;  and 
leave  only  a  temporary  opacity  propor- 
tioned to  their  extent.  If  they  involve 
an  extensive  surface,  even  though  quite 
superficial,  amounting  to  little  more  than 
an  abrasion's  removing  the  corneal  epi- 
thelium, they  may  be  extremely  painful. 
If,  as  often  occurs,  they  are  infected, 
they  present  the  features  of  a  suppurat- 
ing ulcer. 

Clinical  and  pathological  study  of  four 
cases  of  ring  infiltration  of  the  cornea. 
In  every  instance  the  affection  followed  a 
perforating  septic  wound  of  the  cornea, 
and  the  ring  infiltration  occupied  pre- 
cisely the  same  position,  its  outer  edge 
being  one  millimetre  distance  from  the 
corneal  margin,  irrespective  of  the  posi- 
tion of  the  wound.  Microscopically,  the 
cell-accumulation  between  the  laminae 
of  the  cornea  was  found  to  be  densest  at 
a  position  almost  equally  distant  from  its 
anterior  and  posterior  surface,  or  slightly 
nearer  the  anterior.  Collections  of  cells 
were  also  sometimes  found  between  Des- 
cemet's  membrane  and  the  corneal  sub- 
stance. E.  Treacher  Collins  (Ophthalmic 
Review,  Aug.,  '93). 

Injuries  to  the  globe  occur  generally 
to  the  nasal  or  upper  aspect  of  the  bulbus, 
exceptionally  to  the  temporal  side;  the 
cornea  ruptures  oftenest  in  youth,  the 
sclera  in  old  age.  Miiller  ("Ueber  Rupt- 
ure der  Corneo-seleral  Kapsul  (lurch 
Stumpfe  Verletzung"). 

Striate  keratitis  is  seen  after  in- 
jury, especially  after  operations,  like 
cataract  extraction.  In  this  case  a  num- 
ber of  fine-gray  streaks,  more  or  less  per- 
pendicular  to  the  corneal  incision,  are 


SYMPTOMS. 

noticed,  from  a  few  hours  to  a  week  or 
so  after  the  operation.  This  form  may 
also  occur  after  an  injury  that  lias  caused 
bending  of  the  cornea.  It  usually  ends 
in  resolution. 

Filamentary  keratitis  is  more  frequent 
in  the  old  than  in  the  young.  The  pri- 
mary growths  seem  to  originate  from  a 
state  of  prolonged  congestion  of  the  cor- 
nea. These  first  appear  as  little  spheres, 
which  later  become  filamentous.  There 
are  a  few  signs  of  ciliary  irritation:  the 
cornea  clears  and  becomes  normal.  In 
part,  these  filaments  seem  to  have  an 
epithelial  origin,  consisting  of  a  gradual 
elongation  of  the  surface-cells  of  the  cor- 
nea. These  are  mingled  with  cells  that 
are  deposited  from  the  conjunctival 
mucus.  Nuel  (Archives  d'Ophtal.,  Oct., 
'92). 

Suppurative  keratitis  always  in- 
cludes the  formation  of  a  corneal  ulcer; 
and  it  is  probably  always  due  to  some 
form  of  infection.  The  ulcer  may  be 
there  first,  and  become  infected,  or  the 
infection  may  occur  in  a  previously- 
sound  cornea,  giving  rise  to  an  abscess; 
which  in  time  breaks  through,  it'  not 
incised,  forming  the  ulcer.  In  some 
cases  the  posterior  layers  of  the  cornea 
break  down,  forming  an  ulcer  on  the 
posterior  surface. 

Suppurative  ulcer  is  marked  by  a  mar- 
gin which,  at  least  at  some  points,  is  in- 
filtrated, as  the  floor  may  be  infiltrated. 
The  tissue  thus  becoming  involved  in  the 
ulcerative  process  is  swelled,  softened, 
yellowish  in  color,  and  swarming  with 
bacteria.  The  germs  most  commonly 
present  are  the  pus-cocci  or  the  pneumo- 
coccus  (diplococcus  lanceolatus).  This 
latter  form  gives  rise  to  what  is  known 
as  the  serpent-ulcer:  an  nicer  that  is 
liable  to  spread  irregularly  over  a  large 
part  of  the  cornea  without  tending  to 
rapidly  perforate  it.  The  margin  of  such 
an  ulcer  is  generally  of  irregular  outline, 
and  abrupt  or  overhanging.    The  sup- 


KERATITIS. 

purating  ulcer  is  often  attended  with 
hypopyon. 

Xerotic  keratitis  hegins  with  dry- 
ness of  the  conjunctiva;  and  a  general 
haziness  of  the  cornea,  which  soon  leads 
to  ulceration,  perforation,  and  loss  of  the 
eye.  Both  eyes  are  generally  affected; 
the  disease  occurs  in  feeble  infants  that 
rarely  survive. 

Diagnosis. — Keratitis  is  recognized  by 
careful  inspection  of  the  cornea  under 
the  proper  conditions  of  illumination. 
Slight  opacity  is  rendered  most  evident 
by  strong  oblique  illumination  which 
should  be  so  arranged  that  the  light  will 
be  concentrated  upon  the  cornea,  while 
the  iris  behind  it  is  left  in  comparative 
shadow,  to  furnish  a  dark  background. 
Localized  points  of  opacity  in  front  of 
the  pupil  may  also  be  studied  with  the 
ophthalmoscope,  using  the  strongest  con- 
vex lens  behind  the  mirror,  and  looking 
from  about  the  focal  distance  of  the  lens 
in  front  of  the  eye.  Ulceration  is  best 
discovered  by  placing  the  patient  where 
the  light  from  a  large  window  will  be 
reflected  from  the  surface  of  the  cornea, 
such  a  reflex  showing  all  the  irregulari-  I 
ties  of  the  reflecting  surface.  To  make 
sure  that  these  irregularities  are  not 
filled  in  with  mucus,  that  may  render 
them  invisible,  it  is  well  to  wipe  the  sur- 
face with  a  pledget  of  cotton.  Or  to 
outline  an  ulcer  more  distinctly  for  treat- 
ment, it  may  be  stained  with  a  solution 
of  fluorescin,  1  part  ;  sodium  bicarbonate, 
2  parts;  distilled  water,  200  parts;  or 
with  one  of  toluidin-blue  1  to  1000. 

Conjunctivitis. — Keratitis  must  be  ! 
distinguished  from  conjunctivitis.    Le-  j 
sions  of  the  cornea  are  the  most  common  I 
and  the  most  dreaded  complications  of 
conjunctiva,]  inflammation.     But  more 
especially  on  that  account  is  it  necessary 
to  recognize  promptly  when  the  cornea 
becomes  involved.    The  treatment  re-  ; 


DIAGNOSIS.  295 

quired  by  keratitis  is,  too,  in  many  re- 
spects totally  different  from  that  appro- 
priate to  conjunctivitis.  Unless  the  cor- 
nea itself  exhibits  the  characteristic  opac- 
ity or  loss  of  substance,  we  cannot  assume 
that  it  is  affected.  The  redness  of  the 
pericorneal  zone,  while  quite  different 
from  the  typical  redness  of  conjunctivi- 
tis, may  be  completely  hidden  by  swell- 
ing of  the  conjunctiva. 

Iritis. — The  differential  diagnosis  be- 
tween keratitis  and  iritis  is  also  very  im- 
portant. Here,  too,  the  detection  of  the 
actual  lesions  present  in  one  or  the  other 
of  these  structures  is  to  be  relied  on. 
Corneal  disease  may  cause  apparent  dis- 
coloration of  the  iris;  and  in  the  early 
stage  of  keratitis  the  pupil  is  apt  to  be 
very  small.  But  the  use  of  a  mydriatic 
(which  would  generally  be  very  appropri- 
ate for  either  disease)  will,  in  keratitis, 
produce  regular  dilatation  of  the  pupil, 
even  if  it  is  not  as  wide  as  in  the  normal 
eye. 

An  error,  much  more  grave,  is  to  mis- 
take inflammatory  glaucoma  for  keratitis. 
Both  diseases  may  present  pericorneal 
redness,  pain,  photophobia,  and  haziness 
of  the  cornea;  and  glaucoma  shows  im- 
pairment of  the  sense  of  touch  in  the 
cornea,  as  markedly  as  does  neuropathic 
keratitis.  In  the  latter  disease  the  ten- 
sion of  the  eyeball  may  be  diminished; 
in  glaucoma  simulating  keratitis  it  is 
always  increased.  The  pupil  in  glaucoma 
is  more  or  less  dilated;  in  keratitis,  un- 
less a  mydriatic  has  been  used,  it  is  con- 
tracted or  normal.  The  haziness  of  the 
cornea  is  more  uniform  and  diffuse  in 
glaucoma,  while  in  keratitis  it  is  more 
likely  to  be  localized.  Corneal  ulcer 
may  occur  in  glaucoma,  but  usually  only 
in  chronic  cases.  The  chief  pain  of 
glaucoma  is  of  an  aching  character,  and 
is  felt  as  much  in  the1  brow  and  cheek  as 
in  the  eyeball.    That  of  keratitis  is  more 


296 


KERATITIS.    ETIOLOGY  AND  PATHOLOGY. 


likely  to  be  smarting  or  burning,  or  the  j 
sense  of  a  foreign  body.  If  a  mydriatic 
has  been  used  and  the  pupil  has  been 
dilated,  the  tension  of  the  eyeball  and 
the  ophthalmoscopic  symptoms  must  be 
relied  on.  Haziness  of  the  cornea,  suffi- 
cient to  prevent  an  ophthalmoscopical 
diagnosis,  is  not  likely  to  occur  in  glau- 
coma, except  when  the  increase  of  ten- 
sion is  so  great  as  to  be  quite  unmistak- 
able. 

Diagnosis  or  Vaeious  Forms  of 
Keratitis. — The  diagnosis  of  the  par- 
ticular form  of  keratitis  present  is  often 
very  important.  Here  the  character  of 
the  opacity  or  ulceration  may  be  of  great 
significance.  Interstitial  keratitis  will 
be  known  by  the  depth  of  the  opacity, 
the  fine  loops  of  the  vessels,  the  involve- 
ment of  the  iris,  and  the  other  evidences 
of  constitutional  taint.  The  history  of 
a  nerve-lesion  or  the  loss  of  sensibility 
in  the  cornea  point  to  neuropathic  kera- 
titis. In  the  malarial  form  there  is  ob- 
tainable a  history  of  malaria,  and  the 
linear  ulcers  are  in  tissue  having  less 
than  normal  sensibility  to  touch.  In 
dendritic  keratitis  these  features  are  ab- 
sent. Herpetic  keratitis  is  characterized 
by  the  minuteness  of  the  scattered  ulcers 
and  the  history  of  previous  illness;  and 
punctate  by  the  points  of  chief  opacity. 
Bullous  keratitis  is  known  by  the  burn- 
ing pain,  followed  by  the  large  bleb  or 
superficial  abrasion.  Pannus  is  readily 
recognized  by  the  distribution  of  the  ves- 
sels and  the  superficial  opacity;  and  the 
evidence  or  history  of  preceding  con- 
junctival disease.  Traumatic  and  striate 
keratitis  will  give  the  history  of  injury. 
The  suppurative  ulcer  will  be  recognized 
by  the  yellowish  infiltration  of  the  part 
of  the  cornea  into  which  it  is  extending. 

Etiology  and  Pathology. — The  domi- 
nant facts  in  the  pathology  of  corneal 
ulcer  are  that  the  cornea  is  a  tissue 


closely  related  to  the  white,  fibrous  con- 
nective tissue  of  other  parts,  that  it  is 
non-vascular,  that  it  is  peculiarly  pre- 
disposed to  injury  and  infection,  and 
that  it  is  covered  by  epithelium  liable 
to  the  same  injurious  influences  as  the 
epithelium  of  the  conjunctiva.  The 
tendency  of  the  principle  corneal  tissue 
is  shown  in  the  controlling  influence  of 
the  constitutional  causes  of  interstitial 
keratitis  and  the  prolonged  stage  of  reso- 
lution in  all  forms  of  inflammation  in- 
volving the  true  corneal  substance. 

The  absence  of  blood-vessels  is  respon- 
sible for  the  frequent  occurrence  and  dis- 
astrous extension  of  ulcerations,  and  the 
danger  of  the  spread  of  whatever  infec- 
tion may  occur.  The  extension  of  con- 
junctival infections  of  various  kinds  to 
the  cornea  is  what  might  be  expected 
from  the  similarity  of  their  epithelial 
coverings. 

In  pathological  examination  of  11  cases 
of  purulent  keratitis  in  the  human  sub- 
ject, 5  of  which  were  examples  of  ulcus 
cornese  serpens,  4  of  keratomalacia,  and 
2  of  beginning  panophthalmitis,  it  was 
found  that  Descemet's  membrane  re- 
mained intact  unless  there  was  a  com- 
plete perforation  of  the  cornea,  although 
at  times  the  endothelial  cells  upon  the 
posterior  surface  of  this  membrane  were 
absent  in  many  places.  In  these  cases 
the  corneal  parenchyma  was  found  to  be 
cedematous,  the  corneal  spaces  being  en- 
larged and  filled  with  altered  corneal  cells 
and  leucocytes  with  numerous  nuclei. 
In  several  instances  there  was  a  distinct 
exudation  of  fibrin  between  the  lamella* 
of  the  cornea,  especially,  however,  near 
the  ulcer.  The  leucocytes  invaded  the 
membrane  from  the  limbus  and  mainly  in 
the  superficial  layers.  In  the  cases  of 
keratomalacia  only  the  lower  third  of 
the  cornea  showed  inflammatory  change. 
In  the  ordinary  forms  of  ulceration  Bow- 
man's membrane  and  the  corneal  epi- 
thelium were  absent  from  about  the  ulcer. 
In  the  later  stages  of  ulcus  cornea  ser- 
pens the  epithelial  cells  were  greatly  in- 
creased, being  absent  only  from  near  the 


KERATITIS.    ETIOLOGY  AND  PATHOLOGY. 


297 


ulcers.  The  authors  believe  that  hypop- 
yon is  formed  from  the  iris  and  from  the 
surrounding  spaces  of  Fontana  and 
Schlemm's  canal.  In  the  cases  of  pan- 
ophthalmitis the  inflammation  had  ex- 
tended rapidly  through  the  retina.  Uht- 
hoff  and  Axenfeld  (Archiv  f.  Ophthal., 
B.  42,  Ab.  I). 

Literature  of  '96-'97-'98. 

Trophoneurotic  keratitis  differs  in  its 
pathology  from  keratitis  e  lagophthalmo 
in  that  in  the  latter  condition  the  lesion 
of  the  cornea  is  the  result  of  exposure 
from  an  uncovered  cornea,  together  with 
general  loss  of  resistance  on  part  of  all 
the  tissues.  In  trophoneurotic  keratitis 
the  lesion  is  found  under  the  covered 
cornea.  K.  K.  Wheelock  (Ophthalmic 
Rec,  Feb.,  '98). 

Traumatism  and  infection  play  a  part 
probably  in  all  forms  of  ulcerative  kera- 
titis. Germs  are  always  present  in  the 
conjunctiva  and  atmosphere.  So  that  in 
the  absence  of  resisting  power  on  the 
part  of  the  tissues  every  wound  becomes 
infected.  When,  however,  the  germs  are 
markedly  pathogenic,  as  in  the  conjunc- 
tivitis which  attends  chronic  lacrymal 
obstruction,  or  in  that  due  to  acute  in- 
fection of  the  conjunctiva,  the  corneal 
lesion  proves  more  serious.  Swelling  of 
the  conjunctiva  around  the  corneal  mar- 
gin, chemosis,  prevents  the  lids  from 
cleansing  the  cornea,  and  produces  a 
sulcus,  in  which  the  infected  discharges 
tend  to  accumulate.  It  is  in  this  way 
that  chemosis  causes  corneal  involvement 
in  gonorrhoeal  conjunctivitis.  The  pecul- 
iar forms  of  different  ulcers  and  the  way 
they  extend  are  largely  dependent  on 
peculiarities  in  the  growth  of  the  or- 
ganisms that  cause  them.  Thus,  the  ser- 
pent nicer,  with  its  rapid  extension  later- 
ally and  its  abrupt  or  overhanging  mar- 
gin, is  probably  due  to  the  growth  of  the 
pneumococcus,  which  tends  to  spread  be- 
tween the  layers  of  the  cornea  without 
penetrating  them.     Dendritic  ulcer  is 


probably  also  due  to  infection.  Bullous 
keratitis  may  arise  from  obstruction  in 
the  lymph-channels  in  the  part.  Pannus 
is  due  to  traumatisms  by  the  roughened 
lids,  probably  with  an  added  specific  irri- 
tant. Xerotic  keratitis  may  be  infective, 
although  the  so-called  xerosis  bacillus  is 
found  abundantly  in  the  normal  con- 
junctiva. 

Summary  given  of  130  cases  of  keratitis 
interstitialis  diffusa,  including  5  cases  of 
keratitis  interstitialis  annularis.  In  the  5 
cases  of  the  annular  form  of  the  disease 
4  were  over  20  years  of  age.  Its  etiology 
remains  unexplained.  In  125  cases  of  the 
diffuse  form  hereditary  syphilis  could  be 
positively  determined  in  only  40  in- 
stances. Pfister  (Cursalon  Zeit.  f.  Bal- 
neol.,  Mar.,  '90). 

Among  15,000  patients  only  42  cases  of 
interstitial  keratitis  were  found;  of  this 
number  16  were  males  and  26  females. 
As  a  rule,  the  affection  was  bilateral,  in 
only  9  cases  occurring  on  one  side.  The 
average  age  of  development  was  13  1/2 
years,  the  earliest  being  3  months  and  the 
latest  30  years.  The  complications  of 
most  frequent  occurrence  were  affections 
of  the  tractus  uvealis,  and  especially 
iritis;  in  all,  characteristic  teeth  were 
found  in  40  per  cent.  In  more  than  half 
the  cases  hereditary  syphilis  could  be 
proved  (55  per  cent.).  Werndly  ("Kera- 
titis Diffusa,"  '91). 

Clinical,  anatomical,  and  experimental 
facts  point  to  interstitial  keratitis  even 
when  it  is  clinically  a  primary  manifesta- 
tion, being  either  a  symptom  of  an  exist- 
ing or  a  consequence  of  a  previous  morbid 
process  in  the  uveal  tract.  What  may  be 
called  clinically  primary  interstitial  ker- 
atitis appears  to  have  no  uniform  eti- 
ology. Hereditary  syphilis  is  the  most 
important  and  most  frequent  cause;  local 
conditions  may,  however,  influence  the 
proportion  in  which  this  cause  preponder- 
ates. Against  the  exclusive  importance 
of  syphilis  may  be  mentioned:  — 

The  absence  of  other  indications  of 
hereditary  or  acquired  syphilis  in  30  per 
cent,  to  50  per  cent,  of  the  cases. 

The  occurrence  of  interstitial  keratitis 
in  animals. 


.298 


KERATITIS.    ETIOLOGY  AND  PATHOLOGY. 


The  anatomical  demonstration  that  the 
condition  may  sometimes  depend  upon  a 
tubercular  infection  of  the  eye. 

The  fact  that  diseases  of  the  uveal  tract 
may  be  due  to  various  causes. 

Individuals  who  have  never  acquired 
syphilis  may  suffer  in  advanced  life  from 
interstitial  keratitis. 

Hutchinson's  teeth  do  not  appear  to 
occur  in  the  majority  of  cases;  their 
presence  points  to  the  probable,  though 
not  the  certain,  existence  of  hereditary 
syphilis. 

Recurrences  of  interstitial  keratitis  are 
not  uncommon.  E.  v.  Hippel  (Graefe's 
Archiv,  xlii,  2). 

Dendritic  keratitis  considered  an  her- 
petic disease  of  the  cornea  due  to  con- 
stitutional causes,  malarial  poisoning  be- 
ing very  prominent.  Wilder  (Med.  News, 
July  15,  '93). 

Two  cases  of  keratitis,  1  of  them  com- 
plicated with  iritis,  occurring  in  women 
of  advancing  age  suffering  from  malig- 
nant uterine  disease.  The  ocular  trouble 
believed  to  have  been  caused  by  infec- 
tious emboli.  Du  Bois-Reymond  (Zehen- 
der's  klin.  Monats.  f.  Augenh.,  Apr.,  '91). 

Case  of  periodically-occurring  attacks 
of  keratitis,  apparently  depending  upon 
menstrual  disorder  and  chlorosis.  Usu- 
ally both  eyes  were  affected,  the  attacks 
beginning  after  the  appearance  of  the 
flow  and  lasting  a  few  days  longer.  In 
the  intervals  the  eyes  were  well  and  the 
vision  good.  Ransohoff  (Zehender's  klin. 
Monats.  f.  Augenh.,  Aug.,  '91). 

Interesting  case  of  parenchymatous 
clouding  of  the  cornea  following  light- 
ning-stroke in  a  girl  11  years  old.  There 
was  present  almost  complete  amblyopia 
and  marked  blepharospasm.  After  18 
days  the  cornea  cleared  spontaneously, 
and  the  patient  regained  full  visual 
acuity.  Denig  (Munch,  med.  Woch., 
Aug.  20,  '95). 

As  a  result  of  bacterial  study  of  fifty 
cases  of  suppurative  keratitis,  it  is  con- 
cluded thai  the  pneumococcus  is  invari- 
ably the  exciting  agent  in  hypopyon 
keratitis.  The  lacrymal  and  nasal  pas- 
sages abound  with  this  particular  organ- 
ism. Uhthoff  and  Axenfeld  (Berliner 
klin.  Woch.,  Nov.  25,  '95). 

Of  25  cases  of  hypopyon  keratitis,  the 


diplococcus  was  found  in  23,  either  alone 
or  associated  w  ith  a  staphylococcus.  In 
4  cases  the  micrococcus  occurred  in  phleg- 
monous disease  of  the  eye.  Guaita 
(Recueil  d'Ophtal..  June,  '94). 

In  the  majority  of  instances  of  hypop- 
yon keratitis  the  infectious  agent  is  the 
diplococcus  of  Frankel.  In  nearly  all  per- 
sonal cases  the  germ  was  found  in  the 
mouth,  giving  rise  to  the  suspicion  of 
disease  in  that  cavity.  Bassa  (Recueil 
d'Ophtal.,  June,  '94). 

In  the  exudate  of  scrofulous  keratitis 
was  found  a  coccus  colored  by  Gram's 
method,  liquefying  in  gelatin  and  pro- 
ducing keratitis  in  rabbits,  w  hich  was  be- 
lieved to  be  staphylococcus  pyogenes. 
Straub  (La  Sem.  Med.,  May  25,  '92). 

Literature  of  '96-'97-'98. 

Ocular  lesions  due  to  obstetrical  inter- 
ference are  uncommon.  Case  of  keratitis 
observed  in  the  newborn  which  seems  to 
have  resulted  from  a  prolonged  applica- 
tion of  the  forceps.  The  left  eye  alone 
was  affected,  and  its  appearance  sug- 
gested a  purulent  ophthalmia;  but  the 
eyelids  were  more  markedly  swelled  than 
is  the  case  in  commencing  ophthalmia, 
and  there  was  scarcely  any  discharge. 
On  separating  the  eyelids  it  was  seen 
that  practically  the  whole  cornea  was 
cloudy,  and  there  was  intense  conjuncti- 
val hyperemia.  The  treatment  consisted 
in  the  application  of  ice,  atropine,  and 
boric  lotions.  Dujardin  (Jour,  des  Sci. 
Med.  de  Lille.  Nov.  28.  '96). 

No  specimen  ever  seen  that  would  tend 
to  show  that  pus-cells  ever  do  or  can  pass 
through  Descemet's  membrane  into  the 
anterior  chamber:  their  only  way  lies 
through  the  meshes  of  the  ligamentum 
pectinatum.  Alt  (Amer.  -lour.  Ophth., 
May-June,  '96). 

The  etiology  of  interstitial  keratitis  is 
not  well  defined,  but  hereditary  syphilis 
is  undoubtedly  tin'  usual  origin.  Yon 
Hippel  (Arch.  f.  Ophth..  vol.  xlii.  pt.  2, 
"90). 

From  a  clinical  study  of  interstitial 
keratitis  it  is  considered  that  in  the  ma- 
jority of  cases  this  affection  of  the  deeper 
layers  of  the  cornea  is  secondary  to  in- 
lhinnnation  of  the  anterior  part  of  the 


KERATITIS. 

uveal  tract  :  also  that  it  is  due  to  con- 
genital syphilis.  Cook  (Jour.  Amer. 
Med.  Assoc.,  Mar.  7,  '96). 

The  most  various  infectious  diseases, 
nutritional  derangements,  etc..  may  cause 
an  interstitial  keratitis.  Among  such 
causes  by  far  the  most  frequent  is  heredi- 
tary syphilis;  then  comes  tuberculosis, 
acquired  syphilis,  influenza,  malaria,  di- 
abetes, etc.  A.  Greeff  (Sammlung  Zwang- 
loser  Abhand.  aus  dem  Geb.  der  Augenh., 
'97). 

Case  of  relapsing  interstitial  keratitis 
of  uterine  origin.  A  young  woman  aged 
25  years,  for  a  period  of  eighteen  months 
has  had  at  each  menstrual  epoch  visual 
troubles  pertaining  mostly  to  one  eye, 
and  marked  by  the  appearance  of  white 
spots  of  infiltration  in  the  cornea.  The 
ocular  trouble  came  on  eight  days  before 
the  appearance  of  the  menses,  and  disap- 
peared on  their  cessation.  On  one  or  two 
occasions  almost  the  whole  cornea  was 
affected,  and  there  was  intense  peri- 
corneal injection  and  photophobia,  per- 
sisting for  a  month.  The  patient  was  of 
a  scrofulous  disposition.  Vaginal  injec- 
tions and  attention  to  hygienic  measures 
sufficed  to  disperse  the  ocular  attacks, 
and  the  cornea?  have  regained  their  trans- 
parency. Keenig  (Soc.  Franc.  d'Ophtal., 
May,  '97). 

Horner's  conception  of  the  relation  be- 
tween eczema tous  eruptions  of  the  skin 
and  the  anterior  nares  and  the  phlyctenu- 
lar diseases  of  childhood  is  not  always 
apparent,  but  nearly  constant.  The  con- 
ditions that  predispose  to  these  local  dis- 
turbances are  essentially  constitutional 
and  no  local  treatment  is  in  any  large 
proportion  of  cases  to  be  regarded  with 
favor.  On  the  other  hand,  constitutional 
measures  are  of  the  first  importance  and 
may  alone  be  relied  upon  even  in  com- 
plicated eases,  so  far  as  the  eye  is  con- 
cerned as  a  participating  organ.  I).  S. 
Reynolds  (Phila.  Med.  Jour.,  July  1(5, 
'98). 

Prognosis.  —  Interstitial  keratitis  is 
always  slow.  In  rare  cases  it  may  run 
ils  course  in  one  or  two  months;  quite 
as  frequently  il  will  require  that  many 
years.    Intil  it  lias  fairly  begun  to  sub- 


PROGNOSIS.  299 

side  no  one  can  tell  how  severe  or  how 
protracted  the  attack  will  be.  If  seen 
early  it  is  pretty  safe  to  predict  that  the 
eyes  will  get  worse  in  spite  of  all  treat- 
ment before  they  will  begin  to  get  better. 
If  seen  at  the  height  of  the  attack  great 

I  improvement  may  be  promised,  continu- 
ing over  a  long  period.  Useful  vision 
will  probably  be  restored  even  when 
everything  but  light-perception  has  been 
lost.  But  complete  recovery  with  nor- 
mal vision  rarely,  if  ever,  occurs.  If  the 
opacity  is  most  marked  at  the  centre  of 
the  cornea  and  many  fine  vascular  loops 
are  seen  which  extend  but  a  little  way 
on  the  cornea,  the  disease  is  still  in  an 
early  stage.  If  the  vessels  are  rather 
sparsely  diffused  throughout  the  cornea, 
ami  the  opacity  chiefly  confined  to  the 
central  region,  it  is  probable  that  the 
periphery  of  the  cornea  has  already 
el  eared,  and  that  the  most  rapid  improve- 
ment of  vision  is  about  to  take  place. 

For  the  rarer  forms  of  neuropathic 
and  malarial  keratitis  the  prognosis  must 
depend  considerably  upon  the  general 
condition  of  the  patient.  There  is  some 
danger  of  relapses;  and  it  must  not  be 
forgotten  that  ulcers  from  this  disease 

I  are  liable  to  infection,  with  all  the  con- 
sequences thereof.  At  the  best  they  are 
likely  to  leave  the  affected  portion  of  the 
cornea  nebulous  and  irregularly  astig- 
matic. Herpetic  ulcers,  unless  greatty 
neglected,  commonly  leave  no  trace. 
Punctate  keratitis  usually  leaves  the  cor- 
nea slightly  damaged;  and  the  syphilitic 
form  is  very  chronic,  with  quite  incom- 
plete resolution. 

Phlyctenular  keratitis,  if  carefully 
treated,  commonly  leaves  very  little  per- 
manent damage  of  the  cornea.  But,  oc- 
curring in  the  children  of  the  ignorant 
and  careless,  il  is  very  often  neglected; 
so  that  a  large  proportion  of  the  nebulous 
corneas  with  high,  irregular  astigmatism 


300 


KERATITIS.    PROGNOSIS.  TREATMENT. 


are  due  to  it.  It  is  extremely  liable  to 
relapse;  but  the  single  attack  yields 
promptly  to  treatment,  or  terminates 
often  within  two  or  three  weeks  in  spon- 
taneous recovery.  The  tendency  to  recur 
is  the  serious  feature  of  bullous  kera- 
titis. But  permanent  complete  recovery 
may  occur  in  the  cases  due  to  trauma- 
tism . 

Pannus  rarely  ends  in  complete  recov- 
ery. It  depends  largely  on  the  condition 
of  the  lids.  If  these  can  be  rendered 
smooth  and  do  not  press  upon  and  rub 
the  cornea,  it  will  get  comparatively 
clear,  and  free  from  vessels.  But  some 
irregular  astigmatism  always  remains. 
Fortunately  the  disease  does  not  usually 
involve  the  part  of  the  cornea  in  front 
of  the  pupil;  so  that  normal  vision  may 
be  retained.  Striate  keratitis  usually 
clears  up  entirely  in  a  few  days  or  a  few 
weeks.  In  other  forms  of  traumatic 
keratitis  the  prognosis  depends  on  the 
situation  and  extent  of  the  loss  of  sub- 
stance. 

In  suppurative  keratitis  there  is  always 
more  or  less  permanent  opacity;  which 
is  of  serious  or  slight  importance  accord- 
ing to  its  situation.  The  density  of  the 
opacity  is  somewhat  proportioned  to  the 
depth  of  the  ulcer  causing  it.  The  dan- 
ger of  extension  in  an  infected  ulcer  is 
indicated  by  infiltration  of  its  margins 
or  base;  that  is,  by  the  extent  to  which 
the  process  is  invading  new  tissue.  When 
this  extension  ceases,  when  the  ulcer  be- 
comes "clean/5  improvement  is  to  be  ex- 
pected. Ulceration  is  particularly  dan- 
gerous to  the  cornea,  because  it  is  non- 
vascular; and  when,  in  the  course  of  an 
ulcerative  keratitis,  vessels  extend  out 
from  the  limbus,  and  invade  the  floor 
of  the  ulcer  or  the  tissue  immediately 
around  it,  the  danger  of  perforation 
passes  away.  Perforation,  with  prolapse 
of  the  iris  into  the  opening,  always  causes 


I  a  permanent  leucoma,  which  is  serious 
|  according  to  its  size  and  location  (see 
Cornea,  Opacities  of,  volume  ii).  Sup- 
purative disease  of  the  cornea  is  often 
the  starting-point  of  an  infection  that 
ends  in  panophthalmitis,  or  a  slower 
inflammation  of  the  uveal  tract,  and 
chronic  degenerative  changes.  And  per- 
forating ulcer  may  ultimately  cause  sym- 
pathetic disease  of  the  other  eye. 

Treatment.  —  While  the  removal  or 
treatment  of  the  special  causes  varies 
with  the  different  forms  of  keratitis,  cer- 
I  tain  general  principles  are  applicable  to 
J  the  treatment  of  all  kinds  of  corneal  in- 
flammation.   In  the  first  place,  the  gen- 
eral health  of  the  subject  has  much  to 
do  with  the  resisting  power  of  the  cor- 
j  nea,  and  should  be  guarded  and  built 
:  up  in  every  way.    This  does  not  mean 
|  that  stimulants  should  be  used  in  the  ma- 
J  jority  of  cases.    But  it  does  mean  that 
the  patient  should  have  sufficient  nour- 
ishing food,  fresh  air,  enough  exercise 
to  keep  the  circulation  and  respiration 
active,  sunlight  and  the  influences  of 
cheerful  surroundings,   and  plenty  of 
sleep.    To  secure  sleep  it  may  be  neces- 
sary to  give  analgesics;  but  these  should 
J  be  given  in  small  doses,  and  only  to  sup- 
plement the  influence  of  fresh  air  and 
exercise.    It  may  be  well  to  give  a  laxa- 
tive, when  needed  to  promote  digestion; 
but  active  purgation  should  be  avoided. 
Tonics  may  be  indicated,  and  full  doses 
of  tincture  of  the  chloride  of  iron  seem 
to  have  a  distinct  influence  in  checking 
suppuration. 

Use  of  salt-baths  and  the  internal  ad- 
ministration of  sulphide  of  calcium 
strongly  recommended  in  the  treatment 
of  strumous  children  suffering  with 
phlyctenular  keratitis.  Keyser  (Amor. 
Ther.,  Apr..  '93). 

In  rheumatic  sclerokeratitis  the  most 
useful  remedy  is  sodium  salicylate,  60 


KERATITIS.  TREATMENT. 


301 


grains  daily.  Evans  (Pfalz  Centralb.  f. 
Augenh.,  Jan.,  '95). 

Local  measures  must  be  such  as  to 
support,  not  impair,  the  vitality  of  the 
part.  On  this  account  cold  applications 
must  be  avoided,  even  where  they  would 
be  indicated  if  it  were  not  for  the  cor- 
neal lesion.  On  the  other  hand,  any- 
thing that  will  keep  the  eye  continuously 
warm  and  moist,  acting  like  a  poultice, 
is  liable  to  be  injurious.  Applications 
of  hot  fomentations  for  a  few  minutes  at 
a  time,  or  the  more  continuous  applica- 
tion of  dry  heat,  may  be  beneficial.  The 
danger  of  its  poulticing  effect  should 
generally  exclude  the  bandage;  but  un- 
der certain  circumstances  it  may  be  best 
to  use  it.  These  are:  in  neuropathic 
keratitis  when  the  slight  traumatisms  to 
which  the  cornea  is  exposed  when  the 
eye  is  open  decidedly  aggravate  the 
trouble,  and  when  there  has  been  an 
injury  causing  a  clean  loss  of  the  corneal 
substance, — an  uninfected  ulcer.  The 
eye  should  be  kept  closed,  in  any  case 
of  corneal  ulcer,  when  exposed  to  dust 
that  would  be  likely  to  lodge  in  the  cav- 
ity or  be  pushed  into  it  by  the  normal 
movements  of  the  lids. 

In  trophoneurotic  keratitis  treatment 
must  look  to  restoration  of  the  function 
of  the  nerve,  which  is  best  accomplished 
by  the  stimulating  influence  of  the  con- 
stant current,  supplemented  by  strychnia. 
Locally,  bandages  and  hot-water  com- 
presses are  employed.  Wheelock  (Med. 
Rec,  July  26,  '90). 

Simple  method  for  the  treatment  of 
grave  ulcers  of  the  cornea  complicated 
with  hypopyon.  After  washing  the  con- 
junctival sac  with  a  l-to-5000  sublimate 
solution,  the  closed  lids  are  covered  with 
a  thick  compress  of  salolized  gauze,  anti- 
septic cotton,  ami.  finally,  a  damp  tarla- 
tan bandage,  which,  in  drying,  forms  an 
immobile  dressing  and  secures  equal  com- 
pression. This  dressing  is  renewed  every 
three  or  four  days,  till  euro  is  effected. 
Very  satisfactory  results  claimed.  The 
same  success  is  achieved  in  simple  ulcers 


without  hypopyon,  in  scrofulous  ulcers  of 
children,  and  in  all  ulcerative  keratites. 
Valude  (La  Sem.  Med.,  Feb.  11,  '91). 

In  the  treatment  of  keratitis  neuro- 
paralytica  the  chief  indication  is  protec- 
tion to  the  eye  by  occlusive  dry  dressing, 
and  the  application  of  vaselin  and  iodo- 
form, while,  in  general,  treatment  should 
be  directed  to  the  underlying  cause. 
Panas  (Recueil  d*Ophtal.,  Nov.,  '92). 

In  the  treatment  of  corneal  inflamma- 
tions and  opacities  hot  boric-acid  com- 
presses and  calomel  insufflations  found 
most  efficacious.  Chauvel  (Rec.  d'Oph., 
Oct.,  '92). 

Chloride  of  sodium  in  the  strength  of 
4  to  1000  and  the  application  of  a  band- 
age are  the  best  means  of  combating 
keratomalacia.  Berger  (Revue  Gen. 
d'Ophtal.,  May,  '94). 

Literature  of  '96-'97-'98. 

Local  treatment  of  interstitial  kera- 
titis consists  in  keeping  the  pupil  dilated 
with  atropine,  and  the  use  of  warm  com- 
presses or  frequent  warm  bathing  of  the 
eyes  during  the  active  inflammatory 
stages,  with  moderate,  not  excessive,  pro- 
tection of  the  eyes  from  light;  and,  for 
the  residual  opacities  after  the  acute 
stage  has  subsided,  massage  with  a  mer- 
curial or  iodide-of-potash  ointment  (10 
to  20  per  cent,  of  the  yellow  oxide  of  mer- 
cury, or  10  per  cent,  of  iodide  of  potash), 
the  massage  being  done  by  rubbing  the 
cornea  strongly  with  the  finger  through 
the  closed  lids  twice  a  day  for  five  to 
ten  minutes,  a  drop  of  cocaine  solution 
being  previously  instilled  if  the  patient 
is  sensitive.  In  the  constitutional  treat- 
ment no  means  are  to  be  neglected  which 
may  improve  the  condition  of  the  pa- 
tient's general  health,  and,  secondly, 
where  syphilis  is  present,  the  special  in- 
dications are  threefold,  viz. :  mercury, 
sweating,  and  iodide  of  potash.  Decided 
] (reference  given  to  the  inunction  method. 
As  a  sequel  to  the  mercurial  treatment  it 
is  distinctly  advantageous  to  give  the 
patient  a  course  of  iodide  of  potash:  30 
grains  of  the  salt  are  given  per  day, 
until  he  has  taken  25  to  40  drachms.  R. 
Greeff  (Sammlung  Zwangloser  Abhand. 
aus  dem  Geb.  der  Augenh.,  '97). 


302  KERATITIS.  TREATMENT. 


Apparatus  for  applying  steam  in  eye- 
work.  It  is  arranged  so  that  either  one 
or  both  eyes  can  be  steamed  at  the  same 
time.  The  chief  essential  is  that  it  be  so 
constructed  as  to  prevent  the  patient's 
being  burned  by  the  steam.  This  is  here 
accomplished  by  a  diaphragm  with  only 
one-half  millimetre  perforation  placed 
about  halfway  in  each  projecting  arm. 
Just  beyond  this  small  perforation  there 
is  a  larger  external  one.  which  permits 
the  air  to  mix  with  the  steam  before  it 
escapes  from  the  end  of  the  tube.  The 
treatment  is  begun  by  placing  the  eyes 


Steam-generator  for  inflammation,  ulceration, 
and  opacity  of  the  cornea.  {Bissell.) 

of  the  patient  about  six  inches  from  the 
opening  and  gradually  having  him  ap- 
proach to  within  three  inches:  by  so 
doing  the  temperature  of  the  steam  when 
it  reaches  the  eyes  increases  from  100°  F. 
to  112°  F.  The  steaming  is  continued 
from  ten  to  twenty  minutes.  In  this  wax- 
it  has  been  used  in  a  large  number  of 
cases  of  inflammation,  ulceration,  and 
opacity  of  the  cornea,  with  very  gratify- 
ing results.  After  the  steaming  process, 
yellow  -o\ide-of-mereurv  cerate,  calomel 
powder,  resorcin,  or  whatever  agent  seems 
indicated,  is  placed  on  the  cornea,  and 
gentle  massage  made  over  the  closed  lids. 


Elmer  J.  Bissell  (Jour,  of  Ophthal.,  Otol., 
and  Laryng.,  Oct.,  '98). 

In  all  corneal  inflammations  cleanliness 
or  asepsis  is  of  the  highest  importance. 
This  is  to  be  secured  by  clouchings  of  the 
conjunctival  sac,  and  the  wiping  away 
of  discharges  when  this  is  necessary. 

j  If  there  is  no  conjunctival  discharge 
washing  out  the  eye  once  or  twice  a  day 

1  may  be  sufficient.  If  there  is  profuse 
discharge,  cleansing  the  eye  every  hour 
may  be  necessary.  The  solutions  em- 
ployed should  never  be  irritant,  the  2- 
per-cent.  boric-acid  solution,  or  the  nor- 
mal salt  solution  (3  grains  to  the  fluid- 
ounce)  are  the  best.  They  should  be  ap- 
plied at  blood-heat  or  a  little  warmer. 
To  wipe  away  any  masses  of  discharge 
that  accumulate,  swabs  of  absorbent  cot- 
ton moistened  with  the  cleansing  fluid, 
to  prevent  the  cotton  from  sticking  to 
the  eye,  may  be  used. 

In  keratitis  sulcata  mycotica  the  best 
therapeutics  consists  in  mildly-antisep- 
tic and  soothing  applications.  If  these 
prove  inefficient,  in  addition  to  anti- 
septic washes  with  1-per-cent.  bichloride 
solution,  eserine-vasclin  (20  -  per  -  cent, 
strength)  should  be  smeared  into  the 
conjunctival  sac.  as  recommended  by 
Emmert.  Makrocki  (Zehender's  klin. 
Monats.  f.  Augenh..  Mar..  '90). 

Literature  of  '96-'97-'9$. 

The  most  effective  treatment  of  cor- 
neal ulcers  is  antiseptic  washes,  subcon- 
junctival injections,  and  the  galvano- 
cautery.  Abadie  (Rec.  d'Ophtal.,  Mar.. 
*96). 

A  4-per-cent.  solution  of  common  salt, 
used  subconjunctivelv.  found  quite  as 
effective  as  the  different  solution-  of  cor 
rosive  sublimate  in  the  treatment  of  cor- 
neal ulcers.  Wood  White  (Birmingham 
Med.  Rev.,  dan..  *!)(>). 

Formalin  found  to  give  excellent  re- 
sults in  the  treatment  of  infecting  ulcers 
of  the  cornea  and  in  purulent  conjuncti- 
vitis, 'the  strength  to  be  employed  as  a 
collyrium  is  from  1  to  1000  to  1  to  2000. 
Burnetl  (Ophthal.  Rec.,  Mar..  '96). 


Jin  Important  and  Useful  Book  to  Phy- 
sicians, Students,  nurses,  and  Attendants 
in  Fjospitals  for  the  Insane  «  «  «  « 


J\  Primer  of 
Psychology 

•  ♦  •  and .  ♦  ♦ 

mental  Disease 


See  following  Pages 

i 


Exceedingly  useful  as  a  Text-book  for  Med- 
ical Students. 


A  PRIMER 

OF 

Psychology  and  Mental 
Disease 

FOR  USE  IN  TRAINING-SCHOOLS  FOR 
ATTENDANTS  AND  NURSES  AND 
IN  MEDICAL  CLASSES. 

BY 

C.  B.  BURR,  M.D., 

Medical  Director  of  Oak  Grove  Hospital  for  Nervous  and  Mental  Diseases. 
Flint,  Mich.    Formerly  Medical  Superintendent  of  the  Eastern 
Michigan  Asylum.     Member  of  the  American  Medico- 
Psychological  Association,  etc. 


Second  Edition.  Thoroughly  Revised  and 
Illustrated.  116  pages,  5fx8  inches.  Neatly 
Bound  in  Extra  Cloth.  Price,  81.00, 
net,  Post-paid. 


The  Features  of  the  Book  of  Most  Im- 
portance are: 

1.  The  simplification  of  the  study  of 
Psychology:  short  definitions,  plain  language, 
unencumbered  descriptions  of  mental  proc- 
esses and  illustrations. 

2.  The  unique  plan  of  Part  II,  viz. :  The 
discussion  of  mental  disease  in  its  symptom- 
atology from  the  psychological  side;  also  the 
brief  and  practical  definitions  of  insanity 
and  the  classification  of  causes. 


3.  The  thoroughly  practical  character  of 
Part  III:  on  the  management  of  cases  of  In- 
sanity Nothing  vital  is  omitted.  It  is  of 
the  highest  value  for  the  practical  day-to-day 
guidance  of  the  attendant  or  nurse  (or  of 
the  physician,  so  far  as  details  of  care  go). 
It  would  answer  every  reasonable  require- 
ment as  a  rule-book  for  the  government  of 
nurses  and  attendants  in  hospitals  for  the 
insane. 

An  admirably  arranged  and  thoroughly 
complete  index  adds  to  the  practical  value  of 
the  work. 

FROM  REVIEWS  OF  THE  FIRST 
EDITION. 

"This  primer  contains,  in  very  simple  paragraphs, 
much  information  of  value  to  those  in  charge  of  the 
insane.  It  is  characterized  throughout  by  sound  common- 
sense.  There  is  in  it  all  that  an  attendant  need  know 
concerning  normal  mental  processes  and  the  manifes- 
tations of  the  unsound  mind." — The  N.  Y.  Medical 
Record. 


"Dr.  Burr  speaks  with  the  authority  of  a  long  ex- 
perience in  his  specialty,  and  his  remarkably  terse,  clear, 
and  simple  style  has  given  us  truly  a  lmultum  in  parvo' 
of  which  there  was  much  need." — Medical  Sentinel, 
Portland,  Ore. 


"This  little  manual  is  designed  for  the  instruction  cf 
asylum  nurses,  and  is  well  adapted  for  that  purpose.  If 
chapters  on  psychology  and  the  different  forms  of  in- 
sanity are  indispensable  for  thorough  instruction  in 
nursing  in  cases  of  mental  disease,  they  could  hardly  be 
clearer  or  more  condensed  than  those  which  comprise 
three-quarters  of  this  book.  The  practical  part,  how- 
ever, is  the  chapter  on  the  management,  of  cases  of 
insanity.  It  is  full  of  useful  suggestions  and  sound 
advice." — Boston  Medical  and  Surgical  Journal. 


"Dr.  Burr  is  one  of  those  Americans  who,  in  the  words 
of  Matthew  Arnold,  'See  clear  and  think  straight.'  The 
clearness  and  conciseness  of  this  admirable  little  book 
are  just  what  we  expected  from  its  author.  This  hand- 
some little  volume  should  be  in  the  hands  of  every 


nurse,  and  every  physician  should  know  its  merits,  if 
only  for  the  purpose  of  commending  it  to  his  nurses." — 
Medical  Mirror  {St.  Louis). 


"The  forms  of  insanity,  and  the  characteristics  of 
each,  are  clearly  and  admirably  treated,  and  in  a  way 
which  makes  the  book  well  adapted  to  class-room  in- 
struction. It  is  full  of  valuable  suggestions,  derived 
from  years  of  experience  in  the  management  of  the  in- 
sane, and,  well  studied,  it  cannot  help  proving  beneficial 
to  nurses  and  to  patients  under  their  care."— Buffalo 
Medical  and  Surgical  Journal. 


"  We  welcome  this  unambitious  little  book  as  a  step 
in  the  direction  of  a  better  training  of  attendants  by 
imparting  more  specialized  knowledge.  The  language 
is  plain  and  simple,  the  definitions  are  generally  clear 
and  easily  understood,  and  the  arrangement  is  logical 
and  calculated  to  help  the  reader  by  leading  him  up 
from  the  plaiu  and  easily  understood  to  more  complex 
matters. 

"Part  II  is  most  useful,  and  the  author  deserves  great 
praise  for  his  admirable  definitions  of  the  various  forms 
of  insanity." — American  Journal  of  Insanity. 

"  The  little  book  before  us  is  a  very  successful  attempt 
to  bring  the  abstruse  subjects  of  psychology  and  mental 
pathology  within  the  range  of  ordinary  data  of  the 
science  given. 

"Dr.  Burr  is  to  be  congratulated  upon  givingto  students 
of  mental  disease  a  useful  hand-book.  The  scope  of  its 
usefulness  will  not  be  confined  to  the  training-school 
students,  to  whom  it  is  dedicated,  but  may  well  include 
the  many  members  of  the  profession,  who,  from  lack  of 
opportunity  or  deficient  interest,  may  realize  themselves 
inadequately  informed  upon  the  important  phenomena 
of  mental  disease." — Physician  and  Surgeon,  Ann  Arbor, 
Mich. 


The  F.  A.  Davis  Co.,  Medical  Publishers. 

PHILADELPHIA,  1914-16  Cherry  St. 
NEW  YORK  CITY,  117  West  42d  St. 
CHICAGO,  9  Lakeside  Big.,  218-20  S.  Clark  St. 

163—99 


KERATITIS.    TREATMENT.  3Q3 


The  pain  of  keratitis  is  commonly 
lessened  by  instillations  of  atropine  or 
other  mydriatics.  It  may  also  be  miti- 
gated by  brief  applications  of  very  hot 
water  to  the  eye,  or  the  internal  use  of 
acetanilid,  morphia,  or  codeia  in  small 
doses.  It  is  temporarily  relieved  by  co- 
caine. But  this  should  never  be  pre- 
scribed, because  the  after-effects  are  alto- 
gether bad:  and  the  temporary  relief  it 
affords  tempts  the  patient  to  frequently 
repeat  the  applications,  each  of  which 
aggravates  the  disease.    The  new  local 

OB 

anaesthetic,  holocaine,  is  less  likely  to  be 
harmful  when  used  in  this  way,  and  it 
has  a  decidedly  antiseptic  action;  but 
whether  it  is  entirely  safe  is  yet  to  be  de- 
termined. The  best  cure  for  pain  is,  in 
general,  the  cure  of  the  condition  caus- 
ing it.  It  is  in  this  way  that  physos- 
tigmine  (eserine)  quickly  relieves  the 
chronic  very  painful  shallow  ulcers  that 
occur  at  the  margin  of  the  cornea  in 
elderly  people,  with  chronic  catarrhal 
conjunctivitis.  Photophobia  may  be 
lessened  by  the  wearing  of  dark  glasses 
and  the  avoidance  of  sudden  changes  to 
a  bright  light.  But  it  grows  rapidly 
worse  if  the  patient  be  confined  to  a 
dark  room:  and  the  confinement  is  likely 
to  react  unfavorably  on  his  general  phys- 
ical condition.  Of  cour>e,  during  an 
active  keratitis  the  eyes  should,  as  far  as 
possible,  be  allowed  to  rest. 

Excellent  results  from  the  use  of  a 
warm  solution  of  chlorate  of  potash.  5 
grains  to  1  ounce,  in  phlyctenular  ulcera- 
tions of  the  cornea.  Bane  I  Western  Med. 
Reporter.  May.  *!>1  ) . 

For  the  cure  of  hypopyon  keratitis  the 
instillation  of  ;i  solution  of  sulphate  of 
eserine,  ii  grains  to  1  ounce,  and  the  con- 
stant application  of  a  bandage,  together 
witli  general  tonic  treatment  highly 
recommended.  Manche  (Brit.  Med.  Jour., 
dan.  17.  *<)1  I. 

In  a  case  of  recurrent  keratitis  super- 
ficial^ punctata  the  use  of  cocaine  caused 


an  increase  in  the  severity  and  duration 
of  the  attack.  Bronner  (Brit.  Med.  Jour., 
June  18,  '92). 

Literature  of  '96-'97-'98. 

Importance  of  directing  treatment  to 
the  conjunctiva  in  cases  of  keratitis  em- 
phasized, even  where  the  corneal  condi- 
tion seems  to  be  predominating.  Two  in- 
stances of  severe  corneal  lesion  were  cured 
only  when  a  slight  follicular  conjuncti- 
vitis, which  was  present,  was  actively 
treated.  Trousseau  (Archives  d'Ophtal., 
Mar.,  '96). 

Special  Treatment.  —  Interstitial 
keratitis  especially  requires  the  employ- 
ment of  mydriatics  on  account  of  the 
tendency  to  involvement  of  the  iris. 
Atropine  may  be  used  in  solution  of: 
atropine  sulphate,  1;  distilled  water,  60. 
The  frequency  and  freedom  of  its  ap- 
plications may  be  limited  by  the  tend- 
ency to  cause  mydriatic  intoxication. 
When  sufficient  to  keep  the  pupil  well 
dilated,  the  strength  of  the  solution  and 
the  frequency  of  its  application  may  be 
diminished.  Locally,  hot  fomentations, 
and  sometimes  local  bleeding  from  the 
temple,  may  also  be  employed.  But  the 
curative  treatment  is  probably  chiefly 
constitutional:  first,  the  preservation  of 
the  general  health;  and,  after  that,  the 
prolonged  administration  of  mercury  and 
the  iodides  in  moderate  doses.  Codliver- 
oil,  iron,  and  arsenic  are  sometimes  most 
beneficial. 

Little  can  be  done  locally  in  interstitial 
keratitis.  No  treatment  can  prevent  the 
second  eye's  becoming  affected.  Where 
syphilis  can  be  demonstrated,  an  anti- 
syphilitic  treatment  is  indicated  whether 
the  keratitis  is  influenced  thereby  or  not. 
Subconjunctival  injections  have  no  spe- 
cial local  influence.  In  certain  cases  in 
which  there  is  no  indication  of  syphilis, 
salicylate  of  soda  appears  to  do  good. 
The  experience,  so  far.  of  paracentesis  of 
the  anterior  chamber  is  insufficient  1<> 
prove  that  it  has  any  therapeutic  value. 
Iridectomy  is  of  no  value  except  where 


304 


KERATITIS.  TREATMENT. 


there  are  the  well-recognized  indications 
for  its  performance.  In  certain  cases 
where  the  process  is  confined  to  a  small 
peripheral  portion  of  the  cornea  it  may 
sometimes  be  checked  by  the  excision  of 
the  adjacent  subconjunctival  tissue.  E. 
von  Hippel  (Graefe's  Archiv,  xlii,  2). 

For  neuropathic,  malarial,  and  her- 
petic keratitis,  the  general  and  tonic 
treatment  is  of  most  importance,  with 
careful  protection  of  the  eyes  from  irri- 
tants. 

Phenate  of  mercury  recommended  in 
diseases  of  the  cornea,  especially  in  her- 
petic phlyctenular  keratitis.  Galezowski 
(Ann.  d'Ocul.,  Jan.,  '95). 

The  treatment  recommended  to  pre- 
vent keratitis  after  destruction  or  re-  | 
moval  of  the  Gasserian  ganglion  is:  I 
Stitching  the  lids  together  for  the  first 
few  days,  and,  after  the  removal  of  the 
dressings  keeping  the  eye  covered  with 
a  Buller  shield  for  a  month.  For  punc- 
tate keratitis  atropine  should  be  applied. 
Bullous  keratitis  may  be  met  with  atro- 
pine and  hot  applications  during  the  at- 
tack; and  regular  massage  with  some 
mild  ointment  during  the  intervals.  It 
may  also  become  an  indication  for  the 
enucleation  of  a  degenerated  eye. 

Two  cases  of  keratitis  bullosa.  The 
first  was  seen  in  an  otherwise-healthy 
eye.  A  cure  was  seemingly  effected  by 
opening  the  sac,  thoroughly  removing  the 
pellicle,  and  applying  a  4-per-cent.  solu- 
tion of  nitrate  of  silver.  The  second  case 
occurred  in  a  glaucomatous,  sightless  eye. 
Here,  all  treatment  failing  to  perma- 
nently relieve  the  condition,  the  eyeball 
was  enucleated.  Colburn  (Jour.  Amer. 
Med.  Assoc.,  Mar.  5,  '92). 

Literature  of  '96-'97-'98. 

The  great  point  in  treatment,  of  bul- 
lous keratitis  is  prevention.  When  an 
eye  lias  been  injured  by  such  an  accident 
as  a  nail-scratch  it  should  be  carefully 
bandaged  until  healing  is  complete. 
When  once  the  bleb  has  formed,  the  shed 
epithelium  should  be  picked  away,  atro- 


pine instilled,  and  a  bandage  applied. 
Cocaine  should  not  be  used  in  such  cases. 
Edmund  Jensen  (Arch.  d'Ophtal.,  Apr., 
'98). 

Dendritic  ulcer  should  be  scraped  and 
touched  with  a  solution  of  silver  nitrate 
or  formaldehyde  of  a  strength  of  1  to 
60.  Phlyctenular  keratitis  was  long- 
known  as  the  common  form  of  scrofulous 
ophthalmia,  and  must  be  treated  with 
especial  reference  to  the  general  condi- 
tions that  accompany  it.  Out-door  life; 
plain,  readily  digested  food;  and  the 
avoidance  of  sweets,  tea,  and  coffee  must 
be  insisted  on.  Codliver-oil  and  syrup 
of  iodide  of  iron  are  standard  remedies. 
The  child  must  not  be  allowed  to  keep 
the  eye  buried  in  the  pillow  or  handker- 
chief; but  should  be  encouraged  to  over- 
come photophobia  by  exposure  to  the 
light  and  air.  Local  treatment  is  also 
very  important.  Photophobia  will  be  di- 
minished by  the  instillation  of  atropine. 
The  ointment  of:  yellow  oxide  of  mer- 
cury, 1  part;  petrolatum,  60;  should  be 
used  in  the  conjunctival  sac  every  night. 
The  lower  lid  being  drawn  down,  a  piece 
of  the  ointment  the  size  of  a  grain  of 
rice  is  placed  on  its  inner  surface,  and 
the  lids  are  closed  and  then  rubbed 
gently  over  the  eyeball  for  a  minute  or 
two.  If  there  is  much  redness  of  the 
ocular  conjunctiva  or  enlargement  of  the 
veins  on  the  inner  surface  of  the  lids, 
tannin,  1;  glycerin,  60;  should  be  ap- 
plied to  the  everted  lids  every  day  or 
two.  Treatment  should  be  continued 
many  weeks  after  an  attack  to  prevent 
recurrences.  A  most  important  measure 
for  the  same  purpose  is  the  thorough 
eradication  of  all  morbid  conditions  dis- 
coverable in  the  nose. 

Case  of  instantaneous  blindness  ob- 
served in  a  child.  11  years  ohl.  also 
affected  with  strumous  keratitis.  The 
ophthalmoscope  revealed  a  large  extrava- 
sation into  the  choroid  in  the  macular 


KERATITIS. 

region.  Under  the  continued  administra- 
tion of  calomel,  vision  gradually  im- 
proved. Dujardin  (Jour,  des  Sci.  Med.  de 
Lille,  Oct.  13,  '93). 

In  the  treatment  of  phlyctenular  kera- 
titis complicated  by  pannus,  kerotomy 
will  work  a  cure  more  rapidly  and  more 
certainly,  and  absorption  of  the  exudate 
is  more  complete,  than  in  other  methods. 
Verry  (Revue  Med.  de  la  Suisse  Rom., 
Nov.,  '91). 

Pannus  requires  the  thorough  treat- 
ment of  the  morbid  conditions  of  the 
lids  which  cause  it,  sometimes  including 
canthoplasty,  or  other  operations  on  the 
lids  to  relieve  the  cornea  from  abnormal 
pressure.  Other  special  measures  for  the 
treatment  of  opacity  are  mentioned  in 
volume  ii. 

In  oyster-shucker's  keratitis  the  yel- 
low salve  has  proved  useless.  A  compress 
bandage  and  a  mild  sublimate  solution 
(1  to  4000)  used  every  four  hours,  to- 
gether with  an  occasional  drop  of  a  solu- 
tion of  atropia — 1  per  cent. — have  given 
the  best  results.  To  this  treatment  the 
keratitis  responds  promptly,  and  in  a 
week  or  ten  days  the  subjective  phe- 
nomena have  been  so  ameliorated  that 
the  shucker  can  resume  work.  The 
opacity  can  be  detected  by  oblique  illumi- 
nation, and  is  permanent.  R.  L.  Ran- 
dolph (Johns  Hopkins  Hosp.  Bull.,  Nov., 
Dec,  '95). 

Suppurative  keratitis  requires  the 
prompt  and  thorough  removal  of  infect- 
ive discharges  and  infected  tissue  so  far 
as  possible.  Corneal  abscess  should  be 
freely  opened  as  soon  as  it  is  recognized. 
For  infected  ulcers  the  simplest  and  most 
generally  applicable  treatment  is  scrap- 
ing or  curetting.  The  tissue  around  the 
ulcer  should  be  thoroughly  and  repeat- 
edly scraped  toward  the  ulcer  so  as  to 
empty  the  interlamellar  spaces  of  their 
contents;  and  all  softened  tissue  should 
be  removed.  After  scraping,  the  ulcer 
should  be  closely  watched;  and  upon 
any  evidence  of  farther  extension  of 

4- 


TREATMENT.  305 

the  infective  process  thoroughly  scraped 
again. 

In  cases  of  ulceration  of  the  cornea  oc- 
curring in  "lymphatics"  where  the  proc- 
ess of  repair  is  sluggish,  notwithstanding 
that  a  leash  of  blood-vessels  supplies  the 
ulcer,  the  performance  of  peritomy  ad- 
vised. Dunn  (N.  Y.  Med.  Jour.,  June 
17,  '93). 

Equally  as  efficient  as  scraping,  though 
a  little  more  alarming  to  the  patient,  is 
the  application  of  the  actual  cautery. 
This  application  may  be  made  with  the 
galvanocautery  tip;  or  with  a  piece  of 
steel  knitting-needle,  one  end  of  which 
is  held  in  an  alcohol-flame  until  white 
hot,  and  then  quickly  applied  to  the  af- 
fected portions  of  the  cornea.  The  cau- 
terization should  include  all  infected 
parts  of  the  tissue.  After  cauterization 
the  eye  may  remain  undisturbed  for  a 
day  or  more  except  that  it  must  be  kept 
cleansed. 

Two  cases  of  traumatic  keratitis  suc- 
cessfully treated,  after  they  had  resisted 
other  measures,  by  cauterizing  the  ulcer 
with  pure  carbolic  acid.  A.  D.  Williams 
(St.  Louis  Med.  and  Surg.  Jour.,  Jan., 
'90). 

Deliquescent  carbolic  acid  highly 
recommended  as  a  cauterizing  applica- 
tion to  corneal  ulcers.  A  single  cauter- 
ization in  the  commencing  stage  will  at 
once  convert  the  ulcer  into  a  healing 
wound.  Suarez  de  Mendoza  (Annales 
d'Ocul.,  May,  June,  '91). 

In  the  treatment  of  infectious  ulcers  of 
the  cornea,  excellent  results  obtained 
from  touching  the  ulcer  once  or  twice 
daily  with  tincture  of  iodine.  The  ad- 
vantages claimed  are  the  prevention  of 
staphyloma  and  the  formation  of  corneal 
cicatrices  less  opaque  than  those  result- 
ing from  other  methods  of  treatment. 
Chibret  (Recueil  d'Ophtal.,  Sept.,  '91). 

Scraping  and  cauterizing  the  diseased 
tissue  instantly  relieves  the  pain  and 
photophobia  in  ulcerative  keratitis.  The 
new  tissue  is  more  transparent  than  that 
which  follows  any  other  mode  of  treat- 
ment. De  Wecker  (Ann.  d'Ocul.,  July, 
'93). 

-20 


306  KERATITIS. 

The  actual  cautery  considered  appli- 
cable especially  to  sloughing  ulcers,  to 
ulcers  in  which  the  spread  of  local  infec- 
tion is  the  dominant  symptom,  to  ulcers 
which  decline  to  heal  under  moderate 
means.  De  Schweinitz  (Amer.  Jour,  of 
Ophthal.,  Apr.,  '91). 

A  powerful  agency  for  draining  the 
affected  tissue,  and  establishing  lymph- 
currents  that  shall  check  the  progress  of 
infection,  is  the  Saemisch  incision,  made 
by  thrusting  a  narrow  cataract-knife  be- 
neath the  ulcer  and  letting  it  cut  directly 
out  dividing  all  the  affected  tissues  and 
permitting  the  free  drainage  of  fluid 
from  the  anterior  chamber. 

In  cases  of  hypopyon  from  traumatic 
ulcer  the  instillation  of  a  drop  of  a  weak 
solution  of  sulphate  of  quinine  and  atro- 
pine, every  two  or  three  hours,  rarely 
fails  to  cause  absorption,  if  the  case  be 
seen  before  the  pus  has  become  thick 
and  glutinous.  R.  Williams  (Liverpool 
Medico-Chir.  Jour.,  July,  '91). 

In  case  of  extensive  ulceration  of  the 
cornea  and  conjunctiva,  adhesion  pre- 
vented by  the  employment  of  an  eye-shell 
made  of  vulcanized  rubber.  Searles 
(Amer.  Jour,  of  Ophthal.,  June,  '93). 

Literature  of  '96-'97-'98. 

In  ulcus  cornea  serpens  any  procedure 
that  induces  long-continued  abolition  of 
the  anterior  chamber  may  induce  glau- 
coma, and  is,  therefore,  to  be  rejected. 
Sachsalber  (Beit.  z.  Augenh.,  Feb.,  '96). 

Thioform  found  better  than  iodoform, 
boric  acid,  and  all  other  dry  applications 
in  ulcer  of  the  cornea.  Rogman  (Ann. 
d'Oeul.,  Mar.,  '96). 

Methyl-violet  and  subjunctival  injec- 
tions recommended  in  corneal  ulcers. 
Darier  (Rec.  d'Ophtal.,  Mar.,  '90). 

In  keratitis  personal  treatment  is  to 
apply  to  the  floor  of  the  corneal  ulcer 
silver  nitrate  in  30-grain  solution.  Woods 
(Presb.  Hosp.  Rep.,  Jan.,  93). 

Excellent  results  obtained  in  the  treat- 
ment of  hypopyon  keratitis  by  subcon- 
junctival injections  of  corrosive  subli- 
mate (1  to  1000).  Nikolikin  (Vestnik  of 
Ophthal..  Jnly-Oct..  '96) . 

Subconjunctival  injections  of  mercury 


KINO. 

used  in  infectious  keratitis  associated 
with  hypopyon  in  eighteen  cases.  The 
writer  prefers  a  solution  of  the  cyanide, 
1  to  100,  and  injects  as  much  as  5  centi- 
grammes. Fromaget  (Ann.  d'Oeul.,  Apr., 
'96). 

The  treatment  of  filamentous  keratitis 
consists  in  abrasion  of  the  filament,  at 
the  surface  of  the  cornea,  and  the  em- 
ployment of  a  collyrium  of  methyl-violet 
1  to  10,000.  Sourdille  (Le  Prog.  Med., 
Apr.  4,  '96). 

Hypodermic  injections  of  iodine  suc- 
cessfully employed  in  cases  of  parenchy- 
matous keratitis.  Lodato  (Vestnik  of 
Ophthal.,  May,  June,  '97). 

The  acrid  expressed  juice  of  the  bit- 
ter cassava  is  a  useful  remedy  in  the 
treatment  of  corneal  ulcers.  S.  D.  Risley 
(Archives  of  Ophth.,  July,  '98). 

Edward  Jackson, 

Denver. 

KIDNEYS,  DISEASES  OF.  See 

Kenal  Diseases  and  Eexal  Surgery. 

KIDNEYS,  INJURIES  OF.  See  Ab- 
dominal Injuries. 

KINO. — Kino  is  the  inspissated  juice 
of  Pterocarpus  marsupium,  a  leguminous 
tree  of  the  East  Indies  and  Malabar.  It 
is  obtained  from  incisions  into  the  trunk, 
and  is  dried  without  artificial  heat.  It 
occurs  in  fragments  of  a  ruby-red  color, 
without  odor,  and  of  a  sweetish,  astrin- 
gent taste.  It  is  soluble  in  alcohol, 
ether,  boiling  water,  and  alkalies,  hut 
only  slightly  soluble  in  cold  water.  Its 
most  important  constituent  is  kinotannic 
acid.  It  also  contains  kinoin.  a  crystal- 
Line  neutral  substance;  pyrocatechin, 
pectin,  etc.  Kino  is  an  ingredient  of 
the  pulvis  kino  compositus  (B.  P.)  and 
also  of  the  pulvis  catechu  compositus 
(B.  P.). 

Preparations  and  Doses. — Kino.  5  to 
30  grains. 

Tinetuva  kino,  l/a  to  2  fluidrachms. 


KINO. 

Physiological  Action.  —  The  physio- 
logical action  of  kino  may  be  said  to  be 
that  of  its  main  constituents,  kinotannic 
and  gallic  acids,  especially  the  former. 
It  is  an  astringent  and  styptic,  pre- 
serving its  activity  in  these  particulars 
throughout  the  entire  length  of  the  in- 
testinal tract.  Its  value  in  arresting 
intestinal  haemorrhage  is  thus  accounted 
for. 

Therapeutics. — Kino  is  a  mild  astrin- 
gent. It  is  useful  in  serous  diarrhoea, 
for  which  purpose  it  is  generally  com- 
bined with  paregoric  and  chalk  mixture, 
or  exhibited  in  the  form  of  compound 
powder  of  kino  (B.  P.),  which  consists 
of  kino,  15  grains;  powdered  cinnamon, 
4  grains;  opium,  1  grain.  Five  to  20 
grains  are  given  as  a  dose.  Kino  is  a 
serviceable  remedy  in  pyrosis. 

Locally  and  internally  kino  possesses 
some  value  as  an  haemostatic  in -passive 
haemorrhage  from  the  intestines  and 
other  viscera.  The  tincture  may  be  used 
as  an  astringent  gargle  in  pharyngitis 
or  for  relaxation  of  the  uvula.  It  is 
often  an  ingredient  of  injections  in  gon- 
orrhoea and  leucorrhcea.  The  powder 
may  be  applied  as  stimulating  astringent 
dressing  to  chronic  ulcers.  In  relaxed 
conditions  of  the  mouth  and  throat  and 
in  epistaxis  the  tincture  may  be  used 
with  benefit. 

KRAMERIA. — Krameria,  or  rhatany, 
is  the  root  of  Krameria  triandra  and  of 
Krameria  i.rina  (polygalae),  small  shrubs 
growing  in  South  America,  especially  in 
Peru  and  Bolivia.  The  bark  of  the  root 
is  strongly  astringent  in  taste  and  almost 
without  odor.  The  woody  part  is  devoid 
of  taste  and  odor  and  is  relatively  in- 
active. The  smaller  roots  are  therefore 
preferred.    Krameria  contains  about  20 


KRAMERIA.  307 

per  cent,  of  krameria-tannic  acid  (the 
active  ingredient),  gum,  starch,  sugar, 
lignin,  and  a  peculiar  acid  called  kra- 
meric  acid.  An  alkaloid,  rathanine,  has 
also  been  isolated.  Krameria  is  an  in- 
gredient of  pulvis  catechu  compositus 
(B.  P.). 

Preparations  and  Doses. — Krameria, 
5  to  30  grains. 

Extractum  krameriae,  5  to  20  grains. 

Extractum  krameriae  fluidum,  V4  to 
1.  nuidrachm. 

Syrupus  krameriae,  2  to  6  fluidrachms. 

Tinctura  krameriae,  1/2  to  2  flui- 
drachms. 

Trochesci  krameria,  1  to  2  troches. 

Physiological  Action. — The  krameria- 
tannic  acid  gives  to  krameria  physio- 
logical properties  very  similar  to  those  of 
tannic  acid.  It  seems,  however,  to  con- 
centrate its  effects  upon  the  mucous 
membranes;  hence  its  beneficial  influ- 
ence in  all  conditions  characterized  by 
relaxation  of  the  latter:  leucorrhcea,  ca- 
tarrhal disorders  of  the  nose,  pharynx, 
intestines,  etc. 

Therapeutics. — The  value  of  krameria 
depends  upon  the  tannic  acid  which  it 
contains.  It  is  used  largely  as  a  remedy 
for  bowel  disorders,  in  chronic  or  serous 
diarrhoea,  in  dysentery,  and  in  passive 
haemorrhage  from  the  intestines  and 
other  viscera.  In  leucorrhcea  and  gonor- 
rhoea its  astringent  action  is  valuable. 
Chronic  pharyngitis  and  conditions  of 
the  respiratory  mucosae  are  generally 
benefited,  but  tannic  acid  is  more  con- 
venient and  effective. 

KTJSSO.   See  Parasites,  Intestinal. 

KYPHOSIS.  See  Spinal  Curva- 
ture. 


308 


LACRYMAL  APPARATUS.    SECRETORY  APPARATUS. 


LABIA,  DISEASES  OF.    See  Vulva. 

LABOR,  ABNORMAL.  See  Parturi- 
tion. 

LACRYMAL  APPARATUS,  DIS- 
EASES OF  THE. 

Secretory  Apparatus,  Diseases  of  the. 

Dacryoadenitis.  —  Inflammation  of 
the  lacrymal  gland  is  of  rare  occurrence, 
either  in  the  acute  or  chronic  form.  It 
is  indicated  by  swelling  and  oedema  of 
the  upper  lid,  and  pain  and  tenderness 
on  pressure  of  the  gland  and  the  adjacent 
supra-orbital  margin.  The  disease  may 
assume  a  purulent  form,  when  an  abscess 
may  open,  either  upon  the  conjunctiva 
or  through  the  skin. 

Acute  daeryoadenitis  of  the  inferior 
accessory  lobules,  in  a  man  25  years  of 
age.  The  disease  presented  itself  as  a 
small  tumor  under  the  bulbar  conjunc- 
tiva, one  centimetre  up  and  out  from 
the  corneal  limbus.  Antonelli  (Recueil 
d'Ophtal.,  Aug.,  '94). 

Eheumatism,  cold,  syphilis,  septi- 
caemia, and  mumps  have  all  been  ascribed 
as  the  cause  in  various  cases,  while  the 
spread  of  inflammation  from  the  con- 
junctiva and  cornea  has  been  noted  in  a 
number  of  instances. 

Treatment.  —  Hot  applications  and 
poultices  in  the  early  stages,  followed  by 
free  incision  under  the  supra-orbital 
region  as  soon  as  pus  has  formed.  In  the 
chronic  variety  the  local  application  of 
absorptive  ointments,  such  as  the  mer- 
curial and  compound  iodine,  should  be 
employed,  while  iodide  of  potassium, 
mercury,  and  the  salicylates  should  be 
administered  internally.  In  acute  cases 
an  active  calomel  purge  should  be  pre- 
scribed, followed  by  large  doses  of 
quinine. 

In  acute  inflammation  of  the  gland, 
satisfactory    results    from    the    use  of 


L 

quinine,  leeches,  and  mercurial  inunc- 
tions to  the  brow.  .  Chronic  inflammation 
best  treated  by  pressure,  and  the  local 
application  of  iodine.  Galezowski  (Re- 
.cueil  d'Ophtalmologie,  Oct.,  '92). 

Case  of  symmetrical  daeryoadenitis 
in  which  internal  administration  of 
iodide  of  potassium  was  followed  by 
rapid  subsidence  of  the  swelling.  Snell 
(Lancet,  July  23,  '92). 

Case  of  non-suppurative  inflammation 
of  the  lacrymal  glands  occurring  in  a 
negress,  with  a  history  of  rheumatism. 
Mercuric  chloride  and  potassium  iodide, 
with  applications  of  hot  water  to  the 
tumors,  caused  cure.  R.  L.  Randolph 
(Archives  of  Ophthal.,  vol.  xxvi,  No.  1). 

Tumors. — Neoplasms,  such  as  sar- 
coma and  adenoma,  and  hypertrophy  of 
the  gland,  are  of  rare  occurrence.  The 
latter  is  at  times  of  congenital  origin,  but 
is  usually  an  affection  of  later  years.  The 
gland  may  attain  a  large  size,  and  cause 
serious  damage  to  the  eyeball  by  com- 
pression. 

Atrophy  of  the  lacrymal  gland  is  very 
rare,  being  usually  associated  with  xe- 
roma  of  the  conjunctiva. 

Dacryops  is  the  name  given  to  a  cystic 
disturbance  of  one  of  the  ducts  of  the 
gland,  and  occurs  as  a  bluish-pink,  trans- 
lucent, elastic  tissue,  which  is  found 
under  the  conjunctiva  in  the  position  of 
the  gland. 

Lacrymal  fistula  may  form  occa- 
sionally as  a  sequel  of  inflammation  or 
traumatism  of  the  gland,  and  may  cause 
a  constant  discharge  of  tears  through  its 
orifice.  A  similar  condition  has  also 
been  observed  of  congenital  origin. 

Dislocation  of  the  gland  lias  been 
met  with  in  a  few  instances  as  a  result 
of  trauma,  and  in  a  very  few  in  which 
the  prolapse  was  congenital.  In  other 
rare  instances  it  was  spontaneous  in 
origin. 


LACRYMAL  APPARATUS. 


EXCRETORY  APPARATUS. 


309 


Case  of  infant  who  fell  and  ruptured 
the  external  orbital  soft  tissues,  dislo- 
cating the  lacrymal  gland.  The  hernia 
was  reduced  and  the  skin  sutured.  The 
function  of  the  organ  was  not  disturbed. 
Bistis  (Ann.  d'Oculist.,  Dec,  '95). 

Case  of  traumatic  prolapse  of  lacrymal 
gland  in  2  Vo-year-old-boy  due  to  fall  on 
sharp  stones;  excision;  no  perceptible 
difference  in  moistening  of  eyes  or  flow 
of  tears,  confirming  de  Wecker's  theory 
concerning  emotional  lacrymation.  Hal- 
tenhoff  (Ann.  d'Ocul.,  May,  '95). 

Treatment. — Extirpation  of  the  gland 
is  indicated  in  eases  of  neoplasms  and 
extreme  hypertrophy,  or  where  there  is 
obstinate  stillicidium  which  cannot  be 
controlled  in  any  other  way.  This  is 
accomplished  by  removing  the  gland, 
either  directly  through  a  skin  incision 
made  over  the  gland,  or  by  an  incision 
through  the  conjunctiva  after  exposure 
of  the  cul-de-sac,  by  division  of  the  ex- 
ternal canthus.  The  latter  procedure  is 
the  one  usually  employed,  as  the  ptosis 
which  is  apt  to  follow  the  first  men- 
tioned, due  to  injury  of  the  levator,  is 
avoided,  and  the  resultant  scar  is  much 
less  conspicuous. 

Three  cases  of  tumor  of  the  lacrymal 
gland.  The  only  operative  procedure 
indicated  in  the  second  stage  of  the  dis- 
ease is  the  horseshoe-incision,  made  suffi- 
ciently far  from  the  orbital  rim  to  avoid 
injury  of  the  frontal  nerves.  Dianoux 
(Ann.  d'Ocul.,  Aug.,  '94). 

In  case  of  hernia  of  the  lacrymal  gland, 
produced  by  traumatism,  protruding 
portion  removed  without  interfering 
with  the  function  of  the  gland.  Panter 
(Omaha  Clinic,  June,  '92). 

In  treatment  of  catarrhal  lacrymal  ob- 
structions with  epiphora,  ablation  of  the 
palpebral  portion  of  the  lacrymal  gland 
advised  if  symptoms  persist  after  the 
ordinary  treatment  has  secured  a  per- 
meability of  the  lacrymal  passages.  Ter- 
son  (Recueil  d'Ophtal.,  May,  '91). 

The  removal  of  the  lacrymal  gland  is 
a  procedure  demanding  consideration  in 
the  treatment  of  simple  or  complicated 
epiphora,  and  of  those  instances  which 


resist  ordinary  means.  It  is  an  operation 
w*hich  should  be  held  in  reserve  and  as  a 
last  resource.  Palpebral  removal  is  an 
operation  of  choice,  suitable  for  simple 
and  for  the  majority  of  complicated 
cases;  whereas  orbital  removal  is  an 
operation  of  necessity.  True  (Archives 
d'Ophtal.,  May,  '93). 

Excretory  Apparatus,  Diseases  of  the. 

In  contradistinction  to  diseases  of  the 
secretory  portion  of  the  lacrymal  appa- 
ratus, diseases  of  the  excretory  portion 
are  of  very  frequent  occurrence  and  are 
all  characterized  by  the  common  and  an- 
noying symptom  of  tears'  flowing  over 
the  cheek. 

Anomalies  of  the  Puncta  Lacry- 
malia  and  of  the  Canaliculi. — Con- 
genital.— Complete  obliteration  or  ab- 
sence of  the  puncta  as  well  as  double 
puncta  has  been  occasionally  observed. 
At  times  the  puncta  and  canaliculi  may 
be  wanting,  the  canals  being  represented 
by  narrow  grooves  along  the  edges  of  the 
lid. 

Case  of  congenital  epiphora  of  both 
canaliculi  in  one  eye  and  of  inferior  one 
in  other  in  child  complaining  of  epiphora ; 
hereditary  origin.  Lafite-Dupont.  (Ann. 
d'Ocul.,  Apr.,  '95). 

Acquired. — Such  anomalies  are  usually 
ihe  result  of  chronic  inflammations  of 
the  lids  and  conjunctiva,  which  have  dis- 
turbed the  normal  relationship  existing 
between  the  puncta  and  the  bulbar  con- 
junctiva. They  are  frequently  induced 
by  old  age,  due  to  a  senile  relaxation  in 
the  orbicularis  palpebrarum,  and  are  con- 
stantly present  in  paralysis  of  the  seventh 
nerve. 

Two  cases  of  dacryorrhcea  caused  by 
atresia  of  the  puncta  in  consequence  of 
spastic  contracture  of  the  sphincter. 
Seggel  (Zehender's  klin.  Monat.  f.  Augen- 
heilk.,  Sept.,  '90). 

Secretion  of  tears  due  to  the  influence 
of  a  branch  of  the  seventh  pair.  Tribou- 
deau  (Jour,  de  Med.  de  Bordeaux,  Nov. 
3,  '95). 


310 


LACRYMAL  APPARATUS.    LACRYMAL  SAC. 


Lacrymal  gland  supplied  by  the  facial 
nerve.  One-sided  weeping  is  due  to  a 
paralysis  of  that  nerve.  The  gland  is 
only  brought  into  activity  in  the  act  of 
weeping  or  in  forced  lacrymal  secretion. 
Goldzieher  (Revue  Gen.  d'Ophtal.,  Jan., 
'94). 

Eversion  of  the  punctum  is  almost  a 
constant  consequence  of  ectropion,  and 
is  also  present  in  those  rare  cases  when 
the  eyeball  is  so  deeply  set  that  a  triangu- 
lar space  intervenes  between  the  lid  and 
the  globe. 

Complete  obliteration  is  a  not  infre- 
quent result  of  burns  and  traumatisms 
which  have  involved  the  lids,  and  of 
granular  conjunctivitis  and  blepharitis. 
Barely,  the  canal  may  be  blocked  by  a 
cilium  or  polyp,  or  by  leptothrix. 

Cylindrical  grass-blade,  one-half  cen- 
timetre long,  extracted  from  the  upper 
canaliculus  of  a  man.  Rodionoff  (Russ- 
kaia  Meditzina,  No.  8,  '88). 

Case  in  which  abscess  of  the  inferior 
lacrymal  canal  was  found  to  be  caused 
by  a  piece  of  lettuce-leaf  2  millimetres 
long  and  1  millimetre  in  circumference. 
The  foreign  body  had  been  driven  into 
the  nose  and  thence  into  the  nasal  duct 
by  repeated  efforts  of  sneezing.  Malgat 
(Recueil  d'Ophtal.,  Apr.,  '90). 

Mass  of  actinomycoses  removed  from 
lower  canaliculus  of  a  healthy  man. 
Huth  (Centralb.  f.  prakt.  Augenh.,  Apr., 
'94). 

Symptoms. — The  most  common  symp- 
tom of  all  these  anomalies  is  the  constant 
overflow  of  tears.  This  is  annoying  in 
itself,  but,  more  than  that,  it  frequently 
causes  such  irritation  of  the  skin  about 
the  lids,  thai  an  inflammation  is  set  up 
which  causes  contraction  of  the  pails, 
and  still  further  interference  with  the 
proper  canalization  of  the  tears. 

Hyperemia  and  catarrh  of  the  con- 
junctiva are  constantly  present,  consecu- 
tive to  all  forms  of  lacrymal  obstructions. 

Treatment. — Usually  the  simple  dila- 
tation of  the  punctum,  or  the  slitting  up 


of  the  canaliculus,  is  sufficient  to  effect 
a  cure,  with  the  co-operation  of  an  as- 
tringent wash  of  zinc  and  boric  acid. 

In  the  treatment  of  lacrymal  obstruc- 
tion, the  lower  canaliculus  is  slit  with  a 
bistoury  or  scissors  only  to  a  distance  of 
five  millimetres  from  the  puncta,  and 
Bowman's  sounds  passed  for  eight  days 
following.  The  triple-furrowed  sound  is 
introduced  and  allowed  to  remain  in 
place  during  the  remainder  of  the  treat- 
ment, the  instillation  of  a  1-per-cent.  so- 
lution of  zinc  chloride  being  made  along 
its  capillary  furrows.  Libbrecht  (Recueil 
d'Ophtal.,  May,  '91). 

Lacrymal  obstruction  often  success- 
fully treated  by  slitting  upper  canalic- 
ulus. Story  (Ophthalmic  Review.  June, 
'95). 

Literature  of  '96-'97-'98. 

Hypnotism  successfully  used  in  a  num- 
ber of  cases  to  pass  lacrymal  probes, 
and  even  for  slitting  up  the  canaliculus 
without  pain.  A.  E.  Davis  (Post-gradu- 
ate, Nov.,  '96). 

If  the  condition  has  been  brought 
about,  however,  by  a  high  degree  of 
ectropion,  or  is  the  result  of  an  extensive 
burn,  relief  will  be  frequently  difficult  to 
attain,  and  extensive  plastic  operations 
may  be  necessitated  before  the  lid  is 
restored  to  its  normal  position. 

Anomalies  of  the  Lacrymal  Sac  and 
Nasal  Duct. 

Dacryocystitis  or  inflammation  of 
the  lacrymal  sac  may  be  either  acute  or 
chronic. 

Symptoms. — The  disease  is  rarely 
acute,  but  begins  generally  as  a  chronic 
inflammation,  whic  h  manifests  itself  by 
a  slight  swelling  and  redness  at  the  inner 
canthns.  and  by  persistent  and  trouble- 
some lacrymation.  or  by  the  discharge  of 
a  mnco-purulent  secretion  from  the  inner 
canthus  of  the  eye.  Pressure  on. the  sac 
will  express  a  secretion  which  is  either 
mucoid  or  muco-purulent,  either  into  the 
conjunctival  cul-de-sac  or  into  the  nose. 


LACRYMAL  APPARATUS.    LACRYMAL  SAC. 


311 


This  condition  of  affairs  may  persist  and 
the  sac  may  become  chronically  dis- 
turbed, and  give  rise  to  a  tumor  of  con- 
siderable size  (lacrymal  tumor,  or  muco- 
cele). Frequently  the  inflammation  as- 
sumes an  acute  form,  and  the  region  of 
the  sac  becomes  swelled  and  reddened 
and  a  thick  creamy  pus  forms  in  the  sac, 
which  is  only  expressed  after  some  diffi- 
culty. The  pain  is  intense,  and  there  are 
marked  constitutional  symptoms,  such  as 
fever  and  loss  of  appetite.  If  the  parts 
are  undisturbed,  the  skin  ulcerates  and 
is  perforated  usually  beneath  the  ten- 
don of  the  orbicularis  muscle,  and  a  per- 
manent fistula  is  formed.  More  rarely, 
the  opening  in  the  sac  heals,  and  the  for- 
mation of  the  fistula  is  avoided.  As  a  re- 
sult of  the  fistulous  formation,  pus  fre- 
quently burrows  into  the  deeper  tissue, 
and  necrosis  of  the  neighboring  bones  is 
not  rarely  occasioned. 

Etiology. — In  the  great  majority  of 
cases  dacryocystitis  is  secondary  to  dis- 
eases of  the  lacrymo-nasal  duct,  primary 
inflammation  of  the  lacrymal  sac  being 
an  extremely  rare  affection.  It  is  a  dis- 
ease of  adults,  being  rare  in  children, 
when  it  occurs  under  10  years  of  age 
being  usually  significant  of  inherited 
syphilis. 

Seven  cases  of  so-called  blennorrhoea 
of  the  lacrymal  sac  in  newborn  infants. 
This  condition  can  usually  be  accounted 
for  by  an  atresia  of  the  nasal  opening  of 
the  lacrymal  canal,  caused  by  a  failure  of 
absorption  of  the  embryonic  tissues  in 
this  position.  Avoidance  of  sounds  is 
recommended;  slight  digital  pressure  over 
the  sac,  combined  with  frequent  cleaning 
of  the  eye,  will  work  a  cure  in  a  short 
time.  Peters  (Zehender's  klin.  Monats. 
f.  Augenh.,  Nov.,  '91). 

Acute  dacryocystitis  is  a  suppurative 
osteoperiostitis  of  the  orbital  process  of 
the  superior  maxilla,  and  only  seconda- 
rily implicates  the  sac.  Fano  (Journal 
d'Oculist.  et  de   Chir.,  Apr.,  '91). 

Case  of  dacryocystitis  following  slit- 


ting and  probing  of  canaliculi;  total 
blindness.  Valude  (Ann.  d'Ocul.,  Mar., 
'95). 

Fatal  case  of  dacryocystitis  caused  by 
injection  of  3-per-cent.  solution  of  alum 
acetate  into  the  canal.  Leplat  (Recueil 
d'Ophtal.,  Nov.,  '94). 

Fifty  cases  of  dacryocystitis.  In  24 
the  affection  was  bilateral,  and  there  was 
usually  an  interval  of  several  months 
after  the  time  of  infection.  Chauvel 
(Recueil  d'Ophtal.,  May,  '92). 

Dacryocystitis  occurs  upon  the  left  side 
more  frequently  than  upon  the  right,  and 
affects  women  oftener  than  men,  ap- 
pearing on  the  average  toward  the  thirty- 
third  year  of  age,  and  about  six  years 
after  the  beginning  of  epiphora.  The 
predisposing  cause  is  a  depraved  consti- 
tutional state.  Variola  has  been  found 
to  have  occurred  previously  in  41  per 
cent.  Nasal  affections  —  hypertrophic 
and  atrophic  rhinitis,  deviation  of  the 
septum,  and  especially  foetid  atrophic 
rhinitis — seem  intimately  associated  with 
dacryocystitis.  The  bad  condition  of  the 
teeth  in  many  cases  renders  possible  the 
propagation  of  periosteal  inflammation 
from  the  jaw  to  the  lacrymal  mucous 
membrane.  Purulent  ophthalmia,  as  well 
as  hereditary;  direct  traumatism,  and 
osseous  lesions  contribute  to  the  causes 
of  dacryocystitis.  Foucher  (L'Union 
Med.  du  Canada,  Sept.,  '91). 

Literature  of  '96-'97-'98. 

Nasal  condition  examined  in  94  cases 
of  dacryocystitis  showing  that  89  had 
some  nasal  affection,  whereas  in  only  5 
was  the  nose  healthy.  E.  Waggett 
(Ther.  Monats.,  Dec,  '96). 

Examinations  of  the  secretion  from  in- 
flamed tear-sacs  shows  no  one  organism 
is  found  constantly  in  ordinary  mucocele. 
Eyre  (Ophth.  Record,  Nov.,  '97). 

Treatment. — As  inflammation  of  the 
lacrymal  sac  is  dependent  in  most  cases 
upon  disease  of  the  lacrymal  duct,  any 
obstruction  existing  there  should  be  com- 
bated in  the  manner  presently  to  be  de- 
scribed. If  this  has  been  neglected,  how- 
ever, and  an  acute  exacerbation  has  been 
inaugurated,  hot  applications  should  be 


312 


LACKYMAL  APPARATUS.    LACRYMAL  SAC.  STRICTURE. 


made  to  the  tumor,  and  any  pus  evacu- 
ated by  direct  incision  into  the  sac  as 
soon  as  its  presence  is  manifested.  Calo- 
mel and  quinine  should  be  administered 
internally.  If  seen  early,  before  this  pro- 
cedure is  rendered  impossible  by  the 
swelling  of  the  parts,  an  entrance  should 
be  effected  into  the  sac  by  slitting  up 
the  lower  canaliculus,  and  the  abscess- 
cavity  washed  freely  with  a  solution  of 
bichloride  of  mercury  (1  to  8000). 

Sodium  fluoride,  0.5-per-cent.  solution, 
recommended  in  dacryocystitis.  Duclos 
(Archives  Clin,  de  Bordeaux,  June,  '95). 

Rhinalgin  highly  extolled  in  acute  and 
chronic  dacryocystitis.  Rhinalgin  is  pre- 
pared according  to  the  following  formula : 

P*  Alumol,  Vo  grain. 
01.  valerian,  3/8  drop. 
Menthol,  3/8  grain. 
Cocoa-butter,  15  grains. 

Make  one  suppository. 

Sig. :  Use  one  morning  and  night  in 
each  nasal  fossa.  Thomalla  (Centralb. 
f.  prakt.  Augenh.,  Aug.,  '95). 

Ten-volume  peroxide  of  hydrogen  suc- 
cessfully used  in  an  8-year-old  case  of 
lacrymal  abscess  with  fistula.  McCul- 
lough  (Canada  Lancet,  Jan.,  '92). 

In  blennorrhea  of  the  lacrymal  sac  in 
newborn  infants,  mechanical  expression 
of  the  contents  of  the  sac  is,  in  many 
cases,  unnecessary.  Heddaeus  (Zehen- 
der's  klin.  Monats.  f.  Augenh.,  Mar.,  '92). 

Flexible  sound  of  whalebone  employed 
when  the  sac  is  the  seat  of  obstruction. 
Suarez  (Recueil  d'Ophtal.,  May,  '90). 

If  pericystitis  is  seen  in  the  first  two 
or  three  days,  before  suppuration  be  es- 
tablished, it  may  be  aborted  by  a  single 
catheterization.  If  suppuration  is  estab- 
lished, early  incision  advocated.  Pari- 
naud  (Ann.  d'Ocul.,  May,  June,  '91). 

In  lacrymal  obstruction  it  is  possible 
to  thoroughly  cleanse  the  lacrymal  sac 
and  to  inject  any  desired  application  for 
the  relief  of  inflammation  of  its  walls 
through  the  dilated  or  enlarged  punctum 
without  slitting  the  canaliculus.  Proper 
treatment  of  acute  blennorrhea  of  the 
sac,  when  seen  early,  should  consist  in 
the  use  of  hot  compresses  and  antiseptic 


injections.  If  the  swelling  is  great  and 
suppuration  threatens,  an  incision  into 
the  sac  advised,  and,  after  slitting  the 
canaliculus,  the  passage  of  proper  probes. 
Risley  (Jour.  Amer.  Med.  Assoc.,  Sept. 
17,  '92). 

Rapid  cure  of  dacryocystitis  by  a  free 
external  excision  into  the  sac.  After 
curetting  the  sac  a  cannula,  made  of  the 
decalcified  femur  of  a  large  toad,  intro- 
duced into  the  previously  dilated  nasal 
duct.    Guaita  (Ann.  d'Ocul.,  Jan.,  '92). 

Literature  of  '96-'97-'98. 

Ten-per-cent.  solution  of  zinc  chloride 
preferred  as  the  application  in  dacry- 
ocystitis. Frohlich  (Klin.  Monatsb.  fiir 
Augenh.,  Jan.,  '96). 

Stricture  of  the  Lacrymal  Duct. 

Symptoms. — These  are  the  same  as  in 
the  first  stages  of  dacryocystitis,  and  con- 
sist chiefly  in  obstinate  lacrymation  and 
in  the  ability  to  express  a  viscid  matter 
into  the  cul-de-sac  by  pressure  with  the 
finger  upon  the  lacrymal  sac. 

Two  cases  in  which  unsuspected  ob- 
struction of  the  lacrymal  ducts  has 
given  rise  to  symptoms  closely  resembling 
the  prodromes  of  glaucoma.  Galezowski 
(Recueil  d'Ophtal.,  Dec,  '89). 

Three  cases  in  which  stenosis  of  the 
lacrymal  ducts  was  responsible  for  un- 
pleasant symptoms  of  asthenopia.  Trous- 
seau (Recueil  d'Ophtal.,  Feb.,  '90). 

Stricture  of  the  lacrymal  duct  is 
favored  greatly  by  its  relationships  and 
by  the  anatomy  of  its  parts.  The  mucous 
membrane  which  lines  the  bony  walls  of 
the  canal  is  very- vascular,  and  at  certain 
parts  is  thrown  into  folds,  which  swell 
under  slight  provocation  and  offer  suffi- 
cient obstacle  in  themselves  to  prevent 
the  proper  canalization  of  the  tears. 
Again,  the  duct  bears  such  a  close  rela- 
tionship to  the  nose,  that  it  is  necessarily 
exposed  to  all  inflammations  of  this  cav- 
ity. Indeed,  the  great  majority  of  cases 
of  lacrymal  obstruction  are  secondary  to 
acute  or  chronic  disease  of  the  nose.  This 


LACRYMAL  APPARATUS.    LACRYMAL  SAC.  STRICTURE. 


313 


is  particularly  true  of  nasal  disease  of 
syphilitic  origin.  As  a  consequence  of 
its  liability  to  inflammation  by  direct 
continuity  of  structure,  the  nasal  end  of 
the  duct  is  the  most  frequent  seat  of 
stricture,  the  commencement  of  the  duct 
at  the  extremity  of  the  lacrymal  sac  offer- 
ing the  next  most  favorable  site  for  the 
development  of  stricture. 

Thirty  out  of  thirty-five  cases  in  which 
there  was  found,  in  chronic  alteration  of 
the  lacrymal  apparatus,  an  impairment 
of  the  nasal  mucous  membrane  or  a  de- 
flection of  the  nasal  septum.  Kruch 
(Annali  di  Ottalmol.,  No.  3,  '88). 

Four  methods  by  which  nasal  dis- 
orders may  lead  to  eye-symptoms  and 
eye-lesions:  1.  By  processes  of  growth, 
causing  extension  of  tumors  through  the 
sinuses  into  the  orbit  or  into  the  cranial 
cavity,  and  hypertrophies  involving  me- 
chanically the  nasal  end  of  the  duct. 
2.  By  extension  of  infection  through 
lymph-vessels  and  foramina  or  deficien- 
cies in  the  bony  walls,  or  by  continuity 
of  surface;  spread  of  inflammatory  proc- 
esses into  the  lacrymal  sac  and  into  the 
orbit,  thus  affecting  the  intracranial 
portion  of  the  optic  nerve.  3.  By  cir- 
culatory disturbances,  which  occur  in  the 
form  of  venous  congestion  whenever  me- 
chanical conditions  exist  in  the  nose 
which  impede  the  circulation.  4.  By 
nervous  disturbances.  Gradle  (Jour. 
Amer.  Med.  Assoc.,  Sept.  10,  '92). 

Pneumococcus,  a  normal  occupant  of 
respiratory  tract,  may  cause  ocular 
trouble  by  infection  through  lacrymal 
passages  or  endogenetically.  Cuenod 
(Ann.  d'Ocul.,  May,  '95). 

Epiphora  may  result  from  an  obstruc- 
tion of  the  lacrymo-nasal  duct  from 
swelling  of  the  mucous  membrane,  hav- 
ing its  primary  origin  in  chronic  or  sub- 
acute post-nasal  catarrh,  while  the  same 
symptoms  may  arise  from  atrophic 
changes,  with  contraction,  a  part  of  a 
similar  process  in  the  intranasal  passages. 
Lacrymal  abscess  may  be  traced  to 
chronic  pharyngitis,  with  involvement  of 
the  mucous  membrane  of  the  lacrymal 
duct,  producing  true  stricture,  interfer- 
ence with  drainage,  and  development  of 


pathogenic  organisms.  De  Schweinitz 
(Cincinnati  Lancet-Clinic,  May  14,  '92). 

Infection  of  the  conjunctival  sac  by 
bacteria  from  the  nose  is  impossible  by 
way  of  the  lacrymal  canal.  Bach  (Ar- 
chiv  f.  Ophthalmologic,  B.  40,  H.  3,  '94). 

Ozsena  is  a  frequent  cause  of  disease 
of  the  lacrymal  passages.  Van  Milligen 
(Archives  d'Ophtal.,  Nov.,  Dec,  '89). 

Two  cases  of  lacrymation  caused  by 
the  presence  in  the  mouth  of  decayed 
stumps  of  teeth,  through  induction  of 
the  chronic  inflammation  of  the  antrum 
and  the  nasal  fossa,  thence  extending  up- 
ward into  the  nasal  duct.  Puech  (Rec. 
d'Ophtal.,  Nov.,  '95). 

Literature  of  '96-'97-'98. 

In  scrofulous  persons  exostosis  of  the 
nasal  duct  is  a  cause  of  stenosis.  Gale- 
zowski  (Rec.  d'Opht.,  No,  2,  p.  166,  '96). 

Some  eases  of  apparent  closure  of  the 
nasal  duct,  with  all  the  symptoms  of 
dacryocystitis,  are  really  due  to  the  pres- 
ence of  groups  of  actinomycosis.  Evetsky 
(Arch.  d'Ophtal.,  Apr.,  '96). 

Obstinate  unilateral  lacrymation  in  a 
newborn  child  usually  signifies  obstruc- 
tion of  the  tear-duct.  Landolt  (Annales 
de  Gyn.  et  d'Obst.,  Jan.,  '97). 

Among  the  predisposing  causes  of  dis- 
eases of  the  lacrymal  passages  are  such 
defects  of  structure  as  flattening  of  the 
bony  canal  or  other  irregularities,  and 
defects  of  refraction. 

Syphilis,  gout,  phthisis,  scrofula,  or 
any  of  the  infectious  diseases  may  cause 
lacrymal  disorder. 

Among  the  local  causes  are  conjuncti- 
vitis at  the  upper  end  of  the  lacrymal 
passage,  and  nasal  disease  at  the  other 
end,  the  morbid  process  in  either  instance 
spreading  to  the  nearest  canal.  L.  Con- 
ner (Jour.  Amer.  Med.  Assoc.,  July  2, 
'98). 

Treatment. — While  an  absolute  and  a 
complete  cure  of  lacrymal  obstruction 
may  be  frequently  attained,  more  often 
relief  is  only  partial.  If  the  obstruction 
in  the  duet  be  due  to  swelling  of  the 
mucous  membrane  merely,  the  prognosis 
is  good;  but  if  the  stricture  be  of  bony 
origin  it  may  be  regarded  as  incurable. 


314 


LACRYMAL  APPARATUS.    LACRYMAL  SAC.  STRICTURE. 


Treatment  may  be  either  palliative  or 
curative.  The  former  consists  in  re- 
peatedly pressing  the  contents  of  the 
lacrymal  sac  into  the  nose  by  the  finger, 
and  by  the  employment  of  antiseptic  and 
astringent  eye-washes,  or  by  throwing  a 
stream  of  boric-acid  solution  into  the  sac 
by  means  of  an  Anel  syringe.  Attention 
must  be  directed  toward  the  nasal 
mucous  membrane,  and  any  local  irrita- 
tion existing  about  the  nasal  opening  of 
the  duct  must  be  controlled  with  local 
applications. 

In  washing  out  the  lacrymal  passages, 
a  hollow,  conical  cannula,  which  has  its 
lower  opening  upon  the  side  and  a  short 
distance  above  the  terminal  point,  em- 
ployed. Vignes  (Recueil  d'Ophtal.,  Mar., 
'91). 

The  curative  plan  of  treatment  re- 
solves itself  into  some  form  of  surgical 
procedure.  These  measures  have  been 
conveniently  classed  by  Theobald  under 
four  heads:  1.  Those  which  aim  to  re- 
store the  natural  passages.  2.  Those 
which  have  for  their  object  the  forma- 
tion of  a  new  passage  into  the  nose  for 
the  tears.  3.  Those  which  aim  at  the 
obliteration  of  the  natural  passages, — the 
lacrymal  sac  and  duct.  4.  The  removal 
of  the  lacrymal  gland  for  the  purpose  of 
arresting  the  secretion  of  tears. 

The  first  step  toward  the  restoration  of 
the  natural  passages  consists  in  the  oper- 
ation of  Bowman,  which  consists  in  slit- 
ting up  the  lower  canaliculus  throughout 
its  entire  length.  This  is  accomplished 
by  entering  a  fine  canaliculus-knife  into 
the  inferior  punctum,  and  by  slowly 
pushing  it  along  the  floor  of  the  canalic- 
ulus, until  it  abuts  against  the  inner 
wall  of  the  sac  as  it  rests  against  the 
lacrymal  bone.  The  handle  of  the  knife 
should  now  be  swept  upward,  while  an 
upward  and  slightly  backward  inclina- 
tion is  given  to  the  blade  of  the  knife.  A 
ready  entrance  into  the  sac  being  gained 


by  the  successful  accomplishment  of  this 
act,  attempts  should  be  made  to  engage 
the  stricture,  and  to  dilate  its  caliber  by 
means  of  probes.  I  generally  first  make 
the  attempt  with  a  very  small  Bowman 
probe,  and  then  gradually  increase  the 
size  by  passing  slightly-higher  numbers 
every  second  or  third  day.  I  am  satisfied 
after  a  No.  6  probe,  with  a  caliber  of  1.50 
millimetres,  can  be  passed  into  the  nose 
without  difficulty.  Larger  probes  are 
not  employed,  as  they  are  apt  to  injure 
the  mucous  membrane  and  periosteum, 
and  in  some  cases  to  lead  to  necrosis. 
Weber,  Cooper,  and  Theobald,  however, 
think  sounds  of  the  size  of  a  Bowman  No. 
6  quite  inadequate,  and  have  devised 
probes  of  much  larger  caliber,  employing 
instruments  of  a  diameter  of  -1  milli- 
metres in  the  treatment  of  the  majority 
of  their  cases.  As  stated  above,  I  am 
generally  satisfied  with  a  dilatation  of 
1.50  millimetres,  and  alternate  the  pas- 
sage of  probes  by  careful  syringing  of  the 
duct  with  a  weak  solution  of  zinc  and 
boric  acid. 

Routine  slitting  up  of  the  canaliculi  in 
every  case  demanding  treatment  of  the 
lacrymal  sac  or  nasal  duct  deprecated. 
Stenosis  of  the  lower  end  of  the  nasal 
duct  often  can  be  relieved  by  the  galvano- 
cautery.  Gillet  de  Grandmont  (Recueil 
d'Ophtal.,  May,  '90). 

Lacrymal  duct  kept  open  by  passing 
small-sized  cannula  containing  probe 
through  canal ;  cannula  removed  and 
split  pea  of  lead  fastened  to  one  end  of 
thread  pulled  up  until  its  progress  is  ar- 
rested; second  shot  attached  to  upper 
end  near  punctum.  Vilas  (Med.  Rec, 
June,  '95). 

Importance  of  examining  the  nasal 
passages  after  the  passing  of  lacrymal 
probes,  both  in  order  to  determine  their 
position  and  to  detect  the  presence  of  any 
abnormality  which  might  tend  to  ob- 
struct the  lower  end  of  the  ducts.  Cheat- 
ham (Amer.  Tract,  and  News.  Apr.  27. 
'93 ). 

In  stenosis  of  the  nasal  duct,  method 


LACRYMAL  APPARATUS.    LACRYMAL  SAC.  STRICTURE. 


315 


recommended  by  Benson,  which  consists 
in  the  use  of  removable  styles,  intro- 
duced by  the  patient  and  worn  during 
the  night.  Hasbrouck  (Jour,  of  Ophthal., 
Otol.,  and  Laryn.,  Apr.,  '90). 

After  first  obtaining  local  anaesthesia 
by  cocaine,  electrolysis  of  the  lacrymal 
duct  may  be  effected  by  passing  an  ordi- 
nary Bowman  probe  into  position,  and 
then  connecting  the  negative  electrode  of 
a  battery  with  the  handle  of  the  probe 
by  a  serre-fme,  and  effecting  continuity 
of  circuit  by  forcing  a  small  platinum 
tracheotomy  cannula,  to  which  the  posi- 
tive electrode  of  the  battery  has  been 
fastened  into  the  corresponding  nostril 
so  as  to  meet  the  probe.  After  this  has 
been  done,  a  larger-sized  probe  can  be 
readily  introduced.  Gorecki  (Archives 
d'Ophtal.,  Sept.,  '90). 

Summary  of  methods  of  treatment  of 
affections  of  the  lacrymal  apparatus: 
1.  Epiphora:  astringent  and  antiseptic 
collyria.  2.  Catarrh,  with  and  without 
stricture:  in  the  first  case,  catheterism 
by  Bowman's  probes,  followed  by  injec- 
tions of  sublimate,  1  to  3000;  in  the  sec- 
ond, the  injections  will  suffice.  Finally, 
extirpation  of  one  or  both  parts  of  the 
lacrymal  gland.  3.  Suppuration  of  the 
sac:  if  acute,  incision  of  the  anterior 
wall,  bichloride  wash,  and  iodoform 
dressing;  if  chronic,  treatment  for  blen- 
norrhoea;  and,  if  this  fails,  incision  of  the 
sac  and  cauterization  of  the  mucous 
membrane  with  actual  cautery.  4.  Lac- 
rymal fistula  and  fungosities  of  sac: 
thorough  destruction,  by  thermocautery, 
of  the  sac  and  its  surrounding  tissue. 
5.  Alterations  of  the  bony  walls:  open- 
ing, scraping,  curetting,  and  cauteriza- 
tion. Specific  treatment,  if  required. 
Lagrange  (Gaz.  Hebdom.  des  Sciences 
Med.  de  Bordeaux,  Sept.  20,  Nov.  1,  '91). 

Literature  of  '96-'97-'98. 

Use  of  large  probes  urged  in  the  treat- 
ment of  chronic  cases  of  stricture  of  the 
lacrymal  duct.  G.  M.  Black  (Phila.  Med. 
Jour.,  July  10,  '98). 

One  hundred  and  thirty  cases  of  lacry- 
mal stricture  treated  with  the  large 
probes  until  pronounced  cured;  40  of 
these  were  kept  under  observation  for 
periods  varying  from  1  to  8  years  and  re- 


lapse had  occurred  in  only  2  cases.  H.  O. 
Reik  (Phila.  Med.  Jour.,  July  16,  '98). 

In  infants  operative  procedure  should 
be  postponed  until  palliative  measures 
have  been  thoroughly  tried,  although  in 
obstinate  cases  this  may  be  successfully 
accomplished  under  a  general  anaesthetic. 

Treating  lacrymal  blennorrheas  of  the 
newborn  by  the  introduction  of  a  probe 
which  is  made  equal  to  the  thickness  of 
a  No.  3  or  No.  4  Bowman,  and  which 
gradually  tapers  to  a  No.  1  Bowman, 
recommended.  Weiss  (Zehender's  klin. 
Monats.  f.  Augenh.,  Jan.,  '89). 

To  prevent  closure  of  the  duct  after  it 
has  been  made  patulous,  a  number  of 
operators  insert  a  leaden  style,  leaving 
this  in  position  for  several  weeks  or 
months.  This  is  of  especial  value  when 
the  patients  live  at  a  distance,  and  cannot 
submit  to  the  frequent  and  continued 
probing  which  is  necessary  to  attain  the 
best  results. 

Large  probes  employed  in  stricture  fol- 
lowed immediately  by  insertion  of  a  sil- 
ver stylet  into  the  duct.  Fox  (Times 
and  Register,  Dec.  9,  '93). 

In  stricture  of  lacrymal  canal,  sounds 
employed,  which  were  allowed  to  remain 
in  situ  six,  eight,  or  even  ten  days. 
Plettinck  (Recueil  d'Ophtal.,  June,  '94). 

Literature  of  '96-'97-'98. 

Treatment  of  stenosis  of  the  lacrymal 
duct  with  permanent  probes  advocated. 
W.  Vulpius  (Archives  of  Ophthal.,  vol. 
xxv,  No.  2,  '96). 

All  organic  strictures  of  the  lacrymal 
passages  treated  by  means  of  styles,  in 
most  cases  permanently  retained.  The 
stem  of  a  style  should  not  be  straight, 
except  in  the  case  of  a  very  short  duct, 
but  somewhat  concave  outward.  R,  S. 
Miller  (Brit.  Med.  Jour.,  Mar.  13,  '97). 

Other  surgeons  prefer  rapid  dilatation, 
and  insert  probes  of  the  largest  size  into 
the  duct  at  the  first  sitting,  this  being 
usually  performed  under  ether. 


316 


LACTUCAMUM. 


LARYNGITIS. 


Obstruction  of  lacrymo  nasal  duct; 
rapid  dilatation  by  immediate  forcing 
with  wide-lumen  instrument.  Goodman 
and  Ziegler  (Wills  Eye  Hosp.  Reports, 
vol.  i,  No.  1,  '95). 

In  intractable  cases — as,  for  example, 
when  the  stricture  is  bony — two  pro- 
cedures have  been  practiced:  the  removal 
of  the  lacrymal  gland  and  the  oblitera- 
tion of  the  lacrymal  sac.  The  former  of 
these  has  been  modified  by  de  Wecker, 
who  excises  the  little  lobules  and  the 
emissary  ducts  from  both  the  subsidiary 
and  main  lacrymal  glands. 

Obliteration  of  the  sac  is  but  little 
practiced  at  present,  but  is  best  accom- 
plished by  means  of  the  galvanocautery. 
If  a  fistula  remain  after  abscess  of  the 
lacrymal  sac,  it  may  be  healed  by  apply- 
ing the  galvanocautery  to  its  freshened 
edges. 

William  Campbell  Posey, 

Philadelphia. 

LACTATION.  See  Nursing  and  In- 
fant-feeding. 

LACTUCARIUM. — Laetucarium  is  the 
concrete  milk-juice  of  Lactuca  virosa, 
of  the  family  Compositce,  a  wild  variety 
of  lettuce  growing  in  Europe.  It  occurs 
in  irregular,  brown  lumps,  which  are 
wax-like  internally  when  cut,  and  pos- 
sess a  narcotic  odor  and  a  bitter  taste. 
It  is  soluble  in  alcohol,  ether,  and  partly 
soluble  in  water.  Laetucarium  contains 
58  per  cent,  of  lactucerin  (white,  crystal- 
line, and  soluble  in  alcohol),  lactucin 
(bitter  principle  in  fine,  white  scales,  and 
soluble  in  alcohol  and  80  parts  of  water), 
and  lactucic  acid. 

Preparations  and  Doses.  —  Laetuca- 
rium, 5  to  60  grains. 

Syrupus  lactucarii,  a/2  to  2  flui- 
drachms. 

Tinctura  lactucarii,  10  to  60  minims. 
Poisoning  by  Laetucarium.  —  Laetu- 


carium is  a  feeble  narcotic  poison.  When 
taken  in  overdose  the  symptoms  are  sim- 
ilar to  those  of  opium  poisoning.  In 
the  treatment  of  poisoning  by  laetuca- 
rium the  same  measures  that  are  used 
in  opium  poisoning  are  indicated:  the 
stomach  should  be  evacuted  if  possible; 
the  patient  should  be  roused  and  kept 
moving;  apomorphine,  ammonia,  coffee, 
douche,  atropine,  amyl-nitrite,  artificial 
respiration,  and  electricity  may  then  be 
used. 

Therapeutics. — Laetucarium  is  chiefly 
used  in  slight  irritation  of  the  larynx 
to  allay  nervous  irritability  and  in  cases 
where  there  is  an  idiosyncrasy  against 
opium.  The  syrup  is  used  in  cough- 
mixtures  for  children  and  delicate  sub- 
jects. Aubergier's  syrup  and  paste  are 
active,  uniform,  and  palatable.  Lactucin 
may  be  used  as  an  hypnotic  and  sedative 
in  the  close  of  1  to  2  grains. 

LARYNGISMUS  STRIDULUS.  See 

Spasmodic  Laeyngitis. 

LARYNGITIS  AND  KINDRED  DIS- 
ORDERS. 

Definition  and  Varieties. — The  term 
"laryngitis"  means  inflammation  of  the 
larynx;  but  to  properly  distinguish  the 
various  inflammatory  disorders  to  which 
this  organ  is  liable,  several  types  of  laryn- 
gitis are  recognized:  Acute  laryngitis,  in 
which  the  mucous  membrane  alone  is 
supposed  to  be  inflamed;  cedema  of  the 
larynx,  in  which  the  deeper  tissues  be- 
come infiltrated;  symptomatic  laryngitis, 
in  which  cedema  and  phlegmon  may  com- 
plicate acute  laryngitis  as  a  result  of 
microbic  infection;  chronic  laryngitis,  in 
which  any  of  the  lesions  of  inflammatory 
origin  observed  in  the  foregoing  varieties 
have  assumed  chronicity.  These  types 
include  several  disorders  to  "which  indi- 
vidual names  have  been  given,  but  they 


LARYNGITIS.    ACUTE  LARYNGITIS.  SYMPTOMS. 


31 


appear  to  represent  but  stages  or  degrees 
of  the  classical  forms. 
Acute  Laryngitis. 

Symptoms. — Acute  laryngitis  in  the 
majority  of  cases  is  the  result  of  the  tem- 
porary extension  of  a  chronic  catarrhal 
process  existing  in  neighboring  tissues, 
especially  the  nose,  the  pharynx,  or  the 
tonsils.  In  professional  singers,  for  in- 
stance, constant  traveling,  with  its  at- 
tending variations  in  climate  and  tem- 
perature, frequent  exposure  to  dust  and 
smoke,  etc.,  generally  keep  up  catarrhal 
disorder  of  the  nasopharyngeal  tract. 
The  hyperemia  thus  induced  readily  ex- 
tends by  continuity  of  tissue  to  the  vocal 
organs  under  the  influence  of  any  undue 
exposure,  dampness,  cold,  or  any  factor 
capable  of  irritating  the  laryngeal  sur- 
faces. The  larynx  in  such  cases  may  be 
said  to  be  predisposed  to  a  mild  form  of 
catarrh  which  appears  more  or  less  fre- 
quently. In  such  cases  the  subjective 
symptoms  mainly  consist  in  a  constant 
desire  to  "hem"  and  a  feeling  of  constric- 
tion at  the  throat.  The  voice  is  altered 
in  quality  and  pitch;  it  becomes  gruff, 
and  hoarseness,  more  or  less  marked, 
follows.  Under  the  influence  of  proper 
treatment  and  rest  the  local  hyperemia 
quickly  subsides,  but  the  continued  use 
of  the  voice  prolongs  the  inflammatory 
process  and  tends  to  permanently  com- 
promise the  integrity  of  the  organ  as  an 
instrument. 

A  laryngoscopical  examination  some- 
times yields  but  little  evidence  of  inflam- 
mation, the  interarytenoid  space  alone 
showing  slight  hyperemia.  In  the  vast 
majority  of  cases,  however,  the  entire 
larynx  shows  congestion,  the  vocal  bands 
being  distinctly  red.  Much  faith  cannot 
be  placed  upon  these  signs,  in  the  case  of 
male  singers,  however,  the  vocal  bands 
being  frequently  pink  and  even  red  in 
the  normal  state;  but  in  women,  local 


redness  usually  means  active  congestion, 
unless  the  patient  be  addicted  to  excess- 
ive use  of  alcoholic  drinks. 

In  persons  in  whom  the  voice  is  not 
subjected  to  more  than  ordinary  uses,  an 
attack  of  acute  rhinitis  frequently  pre- 
cedes the  laryngeal  disorder.  When, 
however,  the  laryngitis  is  primary, 
hoarseness  usually  occurs  as  the  first 
symptom,  though  slight  chilliness  occa- 
sionally alluded  to  is  a  premonitory  sign. 
The  voice  is  lowered  in  pitch,  a  pricking 
sensation  is  experienced  in  the  larynx, 
which  causes  hacking  and  aggravation  of 
the  local  congestion.  There  is  usually 
some  cough,  slight  dyspnoea,  and  occa- 
sionally some  pain  during  deglutition. 
There  may  be  a  slight  rise  of  tempera- 
ture. The  expectoration,  at  first  jelly- 
like and  viscid,  becomes  more  copious. 
As  this  proceeds,  the  hoarseness  becomes 
more  marked  and  persists  for  some  days, 
sometimes  weeks. 

When  examined  laryngoscopically  the 
larynx  is  found  markedly  congested.  The 
entire  laryngeal  membrane  may  be  in- 
volved, or  the  congestion  may  be  limited 
to  the  vocal  bands  and  the  intra-aryte- 
noid  tissues,  the  redness  gradually  fad- 
ing off  toward  the  upper  portion  of  the 
laryngeal  walls,  except  posteriorly. 

Some  cases  of  acute  laryngitis  are  at- 
tended by  haunorrhagic  symptoms,  the 
expectoration  of  blood  usually  following 
violent  coughing.  Besides  the  usual 
laryngeal  manifestations,  there  is  gener- 
ally to  be  found  a  circumscribed  patch, 
the  seat  of  rupture  of  a  superficial  vessel. 
In  some  cases  there  is  no  expectoration 
of  blood,  but  the  vocal  bands  show  a  red 
spot,  or  localized  hsemorrhagic  infiltra- 
tion. It  sometimes  shows  itself  inde- 
pendently of  a  catarrhal  condition  as  a 
result  of  undue  strain  in  using  the  voice. 
It  is  probable,  however,  that  a  latent 
catarrhal  process  is  always  present  in 


318 


LARYNGITIS.    ACUTE  LARYNGITIS.    SYMPTOMS.  ETIOLOGY. 


such  cases,  and  that  the  vascular  walls 

are  inordinately  weak. 

Case  of  acute  hemorrhagic  laryngitis 
and  record  of  several  cases  hitherto  pub- 
lished. Cardonne  (II  Progresso  Medico, 
Apr.,  '88). 

Hemorrhagic  laryngitis  is  an  acute 
catarrh  of  the  larynx,  accompanied  by 
haemorrhage  of  the  inflamed  mucous 
membrane,  owing  to  certain  peculiar 
conditions,  local  or  general.  La  Placa 
(Archivii  Ital.  di  Larin.,  Oct.,  '88). 

Case  of  hemorrhagic  laryngitis  in  a 
healthy  woman,  30  years  of  age,  two 
months  gone  in  pregnancy.  Attention 
called  to  the  fact  that  three  out  of  six 
cases  reported  by  Strubing  occurred  in 
females  during  pregnancy  or  shortly 
after.  Treitel  (Deut.  med.-Zeit.,  Feb.  9, 
•91). 

Laryngeal  hemorrhage  may  be  of  rheu- 
matic origin.  Immobility  of  the  vocal 
cord,  with  consequent  huskiness,  is  one 
of  the  commonest  manifestations  of  the 
larynx.  G.  Hunter  Mackenzie  (Edin- 
burgh Med.  Jour.,  Dec,  '94). 

Literature  of  '96-'97-'98. 

Laryngitis  hemorrhagica  attributed  to 
the  great  swelling  and  hyperplasia  of  the 
mucous  membrane,  the  increase  in  size 
and  number  of  the  vessels,  the  lessened  re- 
sistance of  their  walls,  and  the  frequent 
and  periodically  increased  blood-pressure 
from  coughing,  hawking,  etc. 

Every  idiopathic  laryngeal  catarrh  is 
entitled  to  be  termed  ''laryngitis  hemor- 
rhagica," which,  without  external  cause, 
and  with  intact  mucous  membrane,  is  ac- 
companied by  hemorrhages  on  or  into 
the  mucous  membrane.  S.  Salzburg 
(Jour,  of  Laryn.,  etc.,  Oct.,  '97). 

(See  colored  plate.) 

The  rheumatic  diathesis  predis- 
poses to  a  disorder  of  the  larynx  simulat- 
ing acute  laryngitis,  but  differing  from  it 
in  that  local  phenomena  are  usually  less 
active  objectively.  The  voice  is  used 
with  difficulty  and  the  pain  is  sometimes 
much  more  severe  than  that  experienced 
in  other  inflammatory  disorders.  There 
is  dyspnoea  in  the  majority  of  cases. 


Rheumatism  of  the  larynx  sometimes 
occurs  in  conjunction  with  general  rheu- 
matism. It  is  a  serious  disorder,  particu- 
larly in  singers;  one  or  both  of  the  crico- 
arytenoid joints  may  be  involved  in  the 
inflammatory  process,  and  permanent 
hoarseness  often  results. 

In  predisposed  patients  the  rheumatic 
laryngitis  may  be  for  weeks  or  months 
the  only  symptom  of  rheumatism.  W. 
Freudenthal  (Jour,  of  Laryn.,  Feb.,  '95). 

Case  of  a  man,  with  acute  generalized 
articular  rheumatism,  in  whom  there  oc- 
curred, as  the  articular  pains  subsided, 
pharyngeal  and  laryngeal  odynphagia, 
and  pharyngeal  dyspnea.  Luc  (Annales 
des  Mai.  de  l'Oreille,  etc.,  Mar.,  '92). 

Five  cases  of  acute  rheumatic  cricoaryt- 
enoid synovitis  following  colds.  Grtin- 
wald  (Berliner  klin.  Woch.,  Xo.  26,  '92). 

If  the  cricoarytenoid  articulation  is 
affected  in  rheumatic  laryngitis,  it  is 
doubtful  if  the  corresponding  vocal  cord 
will  ever  regain  its  normal  range  of 
movement,  and  the  voice  may  be  more  or 
less  permanently  affected.  G.  Hunter 
Mackenzie  (Edinburgh  Med.  Jour.,  Dec, 
'94). 

Etiology. — Generally  speaking,  laryn- 
gitis may  be  said  to  be  due  either  to  con- 
ditions causing  local  congestion  by  mere 
overuse  or  mechanical  irritation,  or  by 
continuity  of  tissue. 

The  forms  thought  to  be  independent 
of  specific  germs  are  those  due  to  ex- 
posure to  cold  and  dam]),  the  inhalation 
of  smoke,  especially  tobacco-smoke  in  a 
badly-ventilated  room,  dust,  irritating 
fumes,  spices,  irritating  particles  of  all 
sorts,  etc.  Excessive  use  of  the  voice  and 
the  ingestion  of  alcoholic  drinks,  of  hot 
or  overspiced  food  are  also  frequent  caus- 
ative factors. 

Nine  cases  of  catarrhal  laryngitis  the 
result  of  bicycling,  tricycling,  etc.  The 
disease  is  attributed  to  the  improper 
position  taken  by  these  subjects  in  their 
exercise,  inclining  the  body  forward  and 
thus  impeding  respiration  and  rendering 
it  necessary  to  respire 'by  tin1  month  as 


LARYNGITIS.    PATHOLOGY.  TREATMENT. 


319 


well  as  the  nose,  while  the  rapidity  of  the 
pace  drives  the  air  into  the  larynx  and 
lungs  under  increased  pressure.  Rago- 
neau  (Revue  de  Laryn.,  etc.,  Nov.  15, 
'91). 

Literature  of  '96-'97-'98. 

Case  of  acute  laryngitis  caused  by 
potassium  iodide.  Contrary  to  the  other 
recorded  cases  of  a  similar  character,  it 
was  not  a  simple  oedema,  but  an  intense 
hyperemia  and  infiltration  of  the  mucous 
membrane  and  of  the  submucous  tissue. 
Frankenberger  (Therap.  Monats.,  vol.  xii, 
No.  4,  '97). 

As  already  stated,  catarrhal  diseases 
of  nose  and  naso-pharynx  greatly  pre- 
dispose to  acute  laryngitis,  and  the  ma- 
jority of  cases  witnessed  show  such  a  con- 
dition as  a  primary  factor.  Singers, 
army-officers,  ministers,  etc.,  are  espe- 
cially prone  to  this  disorder  on  this  ac- 
count, particularly  when  the  voice  is  im- 
properly used;  hut  the  presence  of  a 
primary  catarrhal  disorder  of  the  naso- 
pharyngeal tract  may  usually  he  dis- 
cerned. 

Literature  of  '96-'97-'98. 

Catarrhal  affections  of  the  larynx  are 
always  secondary  to  nasal  and  pharyn- 
geal catarrh.  The  exceptions  to  this  rule 
are  where  the  larynx  has  been  locally  irri- 
tated by  the  inhalation  of  irritant  gases 
or  by  sprays  of  too  strong  a  solution. 
One  other  exception  is  seen  in  public 
speakers,  actors,  and  singers.  Rice  (Post- 
grad., May,  '98). 

Pathology. — In  the  idiopathic,  form  of 
acute  laryngitis  the  superficial  vascular 
supply  is  mainly  at  fault  and  there  are 
very  few  cases  in  which  a  certain  amount 
of  cellular  infiltration  does  not  occur, 
and  the  line  of  separation  between  the 
superficial  and  deeper  changes  is  not 
easily  discerned.  The  primary  factor  in 
such  cases  is  prohahly  vasomotor,  and  if 
the  paresis  of  the  vascular  nerves  is 
marked  the  serous  infiltration  by  dia- 


pedesis  into  the  tissues  may  he  such  as 
to  give  rise  to  slight  tumefaction.  The 
epithelium  may  be  softened  and  localized, 
desquamation  occurring;  diminutive  ero- 
sions are  sometimes  found. 

Treatment. — The  patient  should  re- 
main in  a  warm  room,  refrain  from  talk- 
ing and  smoking,  and  not  allow  others  to 
smoke  around  him.  Hot  food  increases 
the  local  congestion  and  especially  the 
hot  alcoholic  drinks  so  frequently  in- 
dulged in.  Cracked  ice  and  ice-cream  are 
usually  grateful  to  the  patient  and  benefi- 
cent to  his  throat. 

An  acute  attack  of  laryngitis  clue  to 
"cold"  may  often  be  arrested  by  the 
early  internal  use  of  bromide  of  potas- 
sium and  opium.  Twenty  grains  of  the 
former,  with  2  drachms  of  paregoric,  re- 
peated every  three  hours  usually  reduces 
the  laryngeal  hyperesthesia  which  lies 
at  the  bottom  of  the  local  symptoms  to  a 
minimum,  while  the  likelihood  of  any 
complication  is  greatly  decreased.  The 
somnolence  also  induced  tends  to  reduce 
the  localized  congestion.  After  this 
effect  is  obtained,  the  dose  may  be  re- 
duced by  half  and  taken  every  two  hours,, 
two  or  three  times.  A  bottle  of  citrate 
of  magnesium  taken  the  next  morning 
often  brings  on  the  stage  of  resolution. 
This  may  be  encouraged  by  means  of  the 
official  compound  guaiac  lozenges. 

In  some  cases  the  inhalation  of  steam 
impregnated  with  the  compound  tincture 
of  guaiac  is  quite  effective,  but  not  nearly 
as  much  so  as  the  method  given  above, 
which  it  is  calculated  to  replace,  when 
patient  cannot  take  the  bromides.  One 
teaspoonful  of  the  compound  tincture  is 
placed  in  a  pitcher  of  water  as  hot  as 
obtainable;  the  vessel  is  covered  with  a 
towel  folded  into  the  shape  of  a  cone; 
the  mouth  and  nose  are  inserted  into  the 
open  top  of  the  cone,  and  the  steam  is 
inhaled  deeply  as  long  as  it  is  emitted. 


320 


LARYNGITIS.    (EDEMA  OF 


THE  LARYNX.  SYMPTOMS. 


The  inhalation  of  steam  charged  with 
the  compound  tincture  of  benzoin  is  pre- 
ferred by  some  clinicians.  It  may  be 
employed  in  the  same  manner  as  the 
tincture  of  guaiac. 

Literature  of  '96-'97-'98. 

Apomorphine,  1/30  grain,  in  freshly- 
compounded  acidulated  mixture,  recom- 
mended as  a  most  efficient  relaxing  ex- 
pectorant in  acute  laryngitis.  Thomas 
Hubbard  (N.  Y.  Med.  Jour.,  July  18,  '96). 

The  syrup  or  infusion  of  the  leaves  of 
erysium  has  proved  of  great  value,  not 
only  in  restoring  the  quality  of  the  voice, 
but  in  reducing  the  evidences  of  inflam- 
mation in  cases  of  simple  acute  laryngitis. 
In  20  such  cases,  3  doses  daily,  consisting 
of  15  drachms  of  the  syrup  in  an  infusion 
representing  7  1/2  drachms  of  the  leaf,  has 
removed  all  the  functional  disturbance 
in  forty-eight  hours.  Herniary  (Presse 
Med.,  Nov.  20,  '97). 

Inhalations  by  means  of  an  atomizer 
of  a  cold  2-per-cent.  solution  of  ich- 
thyol  repeated  twice  daily,  and  not  too 
deeply  inspired  for  fear  of  producing 
nausea  and  vomiting,  have  given  excel- 
lent results  in  acute  laryngitis.  Ciegle- 
wicz  (Vratch,  xix,  No.  8,  '93). 

In  many  cases  the  local  disorder  is 
greatly  influenced  by  general  disorders. 
In  female  professionals,  especially,  con- 
stipation is  almost  the  rule,  owing  prob- 
ably to  their  irregular  mode  of  living, 
their  varying  diet,  and  the  continued 
traveling  in  railroad-cars.  Purgatives, 
even  mild  aperients,  are,  for  obvious 
reasons,  out  of  the  question  when  even- 
ing after  evening  the  sufferer  is  to  ap- 
pear upon  the  stage.  Enemata,  while 
being  immediately  effective,  present  the 
advantage  of  not  diminishing  the  pa- 
tient's strength.  An  enema  composed  of 
one  pint  of  lukewarm  water  and  a  table- 
spoonful  of  glycerin  will  sometimes  be 
found  to  act  surprisingly,  not  only  on  the 
intestines,  but  on  the  voice,  especially  if, 
as  is  often  the  case  with  traveling  artists, 
the  bowels  have  not  been  moved  for  sev- 


eral days.  If  fever  is  present,  drop  doses 
hourly  of  tincture  of  aconite  will  usually 
reduce  it  markedly. 

In  cases  in  which  the  bromides  and 
opium  cannot  be  given,  a  solution  of  re- 
sorcin  or  alumnol,  7  grains  to  the  ounce, 
should  be  used  with  an  atomizer  about 
every  two  hours  the  first  day,  then  three 
times  daily.  To  enable  the  solution  to 
thoroughly  bathe  the  bands,  the  voice 
should  be  sounded  during  inhalation, 
while  the  fluid  is  being  sprayed  in,  the 
bands  being  thus  brought  in  and  forming 
a  floor,  as  it  were,  at  the  lowest  portion 
of  the  larynx.  When  the  hoarseness  is 
great,  an  application  with  cotton  pledget 
of  carbolized  iodotannin  or  a  solution  of 
perchloride  of  iron,  20  grains  to  the 
ounce,  causes  a  sudden  contraction  of  the 
capillaries,  which  is  effectively  main- 
tained by  the  resorcin  solution. 

To  hasten  the  process  of  resolution,  a 
pill  composed  of  1  grain  of  quinia  and  V4 
grain  of  mix  vomica,  administered  every 
two  hours  the  first  day,  then  four  times 
a  day.  Mariani's  coca-wine,  a  wine-glass- 
ful being  taken  every  three  hours  during 
the  day,  is  especially  effective  in  this  con- 
nection, but  the  last  dose  must  be  taken 
at  least  three  hours  before  using  the 
voice  professionally. 

In  the  treatment  of  rheumatic  dis- 
orders of  the  larynx  local  measures  arc 
practically  useless.  The  benzoate  of  so- 
dium is  sometimes  quite  effectual,  5 
grains  being  given  every  three  hours. 
Salicylate  of  sodium  is  the  standard 
remedy  when  it  can  be  tolerated.  (See 
Rheumatism.) 

(Edema  of  the  Larynx. 

(Edematous  infiltration  of  the  larynx 
may  occur  as  the  result  of  a  simple  ca- 
tarrhal process,  of  traumatic  laryngitis, 
or  as  a  complication  of  infectious  dis- 
orders, proximate  or  remote. 

Symptoms. —  The  first  manifestation 


LARYNGITIS.    (EDEMA  OF  THE  LARYNX.  SYMPTOMS. 


321 


may  be  a  chill,  soon  followed  by  hoarse- 
ness and  laryngeal  pain.  The  most 
prominent  symptom  experienced  almost 
from  the  start  is  a  sensation  of  constric- 
tion at  the  throat  and  gradually  increas- 
ing dyspnoea,  most  marked  during  in- 
spiration. There  is  also  local  heat,  dry- 
ness, and  a  muffled  cough,  which  the  pa- 
tient aggravates  by  efforts  to  rid  the  sur- 
faces of  a  supposed  secretion.  There  is 
increasing  huskiness,  both  inspiration 
and  expiration  being  finally  impeded.  In 
favorable  cases  there  is  a  gradual  decline 
of  all  symptoms;  but  this  course  is  not 
always  observed,  and,  unless  prompt  re- 
lief is  afforded,  the  patient  dies  of 
asphyxia.  The  temperature  is  not,  as  a 
rule,  much  above  the  normal. 

Nine  cases  of  acute  laryngitis  suffi- 
ciently grave  to  cause  dyspnoeic  recession 
of  the  chest  during  inspiration.  The 
pulse  invariably  became  small  during  the 
same  period.  As  the  disease  progressed, 
the  symptom  became  more  and  more 
marked  until,  just  before  tracheotomy 
was  done  in  the  cases  requiring  it,  the 
pulse  was  found  to  be  almost  impercep- 
tible during  inspiration.  The  moment 
the  trachea  was  opened  and  air  allowed 
to  freely  enter  the  chest  the  pulse  re- 
sumed its  regularity  in  volume  and 
rhythm.  Brockbank  (British  Med.  Jour., 
June  24,  '93). 

Case  of  acute  oedema  characterized  by 
the  following  features:  (1)  the  absence 
of  any  known  causative  agency  and  con- 
stitutional symptoms;  (2)  the  extent 
of  cedema  which  may  occur  without 
marked  dyspnoea;  (3)  the  peculiar  char- 
acter of  the  voice;  (4)  the  marked 
benefit  of  prompt  treatment  without 
scarification;  (5)  the  possibility  of  the 
case's  belonging  to  a  group  of  obscure 
clinical  manifestations  known  as  angio- 
neurotic oedema  or  allied  vasomotor 
phenomena.  J.  H.  Pry  or  (Med.  Record, 
July  28,  '94). 

The  laryngoscopical  examination  re- 
veals local  changes  varying  with  the  cause 
of  the  oedema.    When  the  latter  is  sec- 

4- 


ondary  to  acute  laryngitis,  the  upper  por- 
tion of  the  larynx  over  which  the  tissues 
are  comparatively  loose  are  swelled  and 
red  or  reddish  yellow.  The  epiglottis 
sometimes  appears  as  a  thick  cushion, 
covering  two  sausage-like  bodies  under  it, 
the  aryepiglottic  folds.  As  the  tissues 
swell,  these  tend  to  roll  inward,  forming 
a  series  of  cushions  whose  edges  gradu- 
ally approach  one  another,  steadily  re- 
ducing the  lumen  of  the  laryngeal  cavity. 
When  the  oedema  is  the  result  of  trau- 
matism or  contact  with  corrosive  acids, 
etc.,  there  is  great  redness  and  supple- 
mentary local  lesions.  Marked  inflam- 
matory swelling  also  attends  the  erysipel- 
atous form. 

When  cedema  is  due  to  a  general  dis- 
order, the  mucous  membrane  is,  as  a  rule, 
paler  than  when  it  occurs  as  a  complica- 
tion of  a  local  inflammatory  process. 

In  cedema  of  the  entrance  of  the  larynx 
the  passage  to  the  glottis  is  obstructed 
most  especially  by  swelling  of  the  inner 
layer  of  the  aryepiglottic  folds,  which 
lie  like  two  morbid  growths  upon  the 
ventricular  bands,  and  thus  become  a 
great  impediment  to  respiration.  Hajek 
(Archives  Gen.  d'Hydrol.,  etc.,  B.  42,  H. 
1,  '91)  . 

In  oedema  occurring  as  a  result  of  in- 
halation of  steam,  fire,  caustic  vapors,  or 
to  the  deglutition  of  too  hot  liquids,  or 
corrosive  substances  taken  accidentally  or 
with  suicidal  intent,  such  as  carbolic  acid, 
sulphuric  acid,  etc.,  the  onset  of  the 
symptoms  is  comparatively  sudden. 
Dyspnoea  and  spasm  sometimes  occur 
from  the  start,  and  all  the  symptoms  of 
acute  laryngitis  enumerated  are  increased 
in  intensity.  The  gravest  local  mani- 
festation of  laryngeal  inflammation, 
oedema,  is  soon  reached.  In  the  majority 
of  cases  met  with,  however,  after  a  series 
of  acute  manifestations,  momentary 
dyspnoea  and  laryngeal  spasm,  etc.,  which 
the  physician  does  not,  as  a  rule,  witness, 
21 


322       LARYNGITIS.    (EDEMA  OF  THE  LARYNX.    ETIOLOGY  AND  PATHOLOGY. 


the  larynx  assumes  a  comparatively  nor- 
mal condition,  as  far  as  the  patient  goes, 
though,  however,  the  laryngeal  struct- 
ures become  infiltrated  and  after  a  few 
hours — sometimes  an  entire  day — the 
most  distressing  symptoms  appear,  and 
the  patient  dies  asphyxiated,  unless  re- 
lieved.   (See  colored  plate.) 

The  upper  portion  of  the  larynx  may 
show  evidence  of  tissue-destruction  when 
such  agents  as  carbolic  acid,  ammonia, 
etc.,  have  been  used;  but  in  the  majority 
of  cases  laryngoscopieal  examination  only 
reveals  intense  redness  of  all  the  laryn- 
geal tissues,  with  slight  swelling.  The 
active  congestion  may  be  localized,  this 
depending  upon  the  causative  agency. 
In  laryngitis  due  to  burning  fluids  the 
epiglottis  may  alone  be  involved,  but  in 
the  vast  majority  of  cases  neighboring 
pharyngeal  tissues,  the  interarytenoid 
space,  the  ventricular  bands,  and  the 
vocal  bands  take  part  in  the  inflamma- 
tion. 

Etiology  and  Pathology. — The  oedema 
occurring  as  a  result  of  simple  catarrhal 
laryngitis  is  usually  brought  on  by  undue 
exposure  to  damp  cold  air  while  the  body 
is  overheated  by  violent  exercise,  such  as 
dancing,  fencing,  etc.    Decollete  gowns 
and  the  luxury  of  sitting  at  an  open  win- 
dow after  dancing,  and  drinking  of  ice- 
water,  have  thus  caused  many  victims — 
sudden  deaths  credited  to  heart  disease. 
Two  cases  of  oedema  tons  laryngitis  re- 
quiring  tracheotomy,   both   caused  by 
drinking   ice-water   when   the  patients 
were  in  an  overheated  condition.  Vladi- 
mir A.  Paduecheff   (Trans.  Ural  Med. 
Society,  p.  20,  '92). 

Case  of  oedema  of  the  epiglottis,  the  re- 
sult of  a  chill  while  the  patient  was  on 
duty  at  a  railway-station.  Tracheotomy 
was  necessary.  The  patient  recovered. 
F.  Taliaferro  (Chicago  Mod.  Jour,  and 
Examiner,  Sept.,  '88). 

Case  of  oedematons  laryngitis  follow- 
ing cold,  in  a  vigorous  soldier.  Trache- 
otomy became  necessary.     L.  Dorange 


(Archives  de  Med.  et  de  Pharma.  Milit., 
July,  '92). 

(Edema  of  the  larynx  has  also  been  ob- 
served in  cases  treated  with  iodide  of 
potassium,  the  connection  between  the 
disease  and  drug  being  shown  by  the  re- 
duction of  the  oedema  when  the  drug  is 
withdrawn.  (See  Iodine,  in  this  vol- 
ume.) 

Two  cases  of  oedema  due  to  iodide  of 
potassium.  The  first  was  a  carcinoma 
of  the  larynx,  in  which  an  antisyphilitic 
treatment  was  instituted  to  eliminate 
the  possibility  of  syphilis.  After  about 
15  grains  of  iodide  of  potassium  had  been 
taken,  laryngeal  oedema  developed  to 
such  an  extent  that  a  tracheotomy  was 
required.  In  the  second  case,  which  was 
thought  to  be  syphilitic,  the  epiglottis, 
arytenoids,  and  ventricular  bands  were 
cedematous,  and  the  patient  suffered  from 
dyspnoea.  On  administering  iodide  of 
potassium  for  a  day  or  two,  the  oedema 
and  dyspnoea  increased.  After  leaving 
off  the  iodide  of  potassium  the  oedema 
quickly  improved  in  both  cases.  The 
remedy  was  administered  later  in  the 
second  case,  without  causing  oedema. 
Schmiegelow  (Archiv  f.  Laryn.,  vol.  i, 
No.  1,  '93). 

It  is  probable  that  a  latent  disorder  of 
the  larynx  is  present  in  such  cases.  This 
may  have  existed  before  the  use  of  ' the 
iodide  or  occur  as  a  result  of  the  disease 
— syphilis,  for  instance — for  which  the 
drug  has  been  administered.  Lesions  of 
the  kidney  may  mechanically  induce 
laryngeal  oedema  by  interfering  with  the 
free  elimination  of  fluids. 

(Edema  of  the  larynx  may  be  a  diag- 
nostic sign  of  disease  of  the  kidney. 
Abate  (Med.  Bulletin,  Oct.,  '95). 

Three  cases:  (1)  oedema  of  epiglottis 
as  the  first  symptom  of  chronic  nephritis ; 
(2)  acute  oedema  of  right  arytcno- 
epiglottic  region,  apparently  due  to  trau- 
matism from  a  piece  of  bread;  (3) 
oedema  of  epiglottis  and  laryngeal  vesti- 
bule in  a  case  of  variola,  with  scarifica- 
tion and  recovery.  A.  Bandler  (Friiger 
med.  Woch.,  vol.  xiii,  Xo.  19,  '88). 


ffurk  3  HcFalndqe  Co  lift  PhOa. 


LAKYNGITIS.    (EDEMA  OF  THE  LARYNX.    ETIOLOGY  AND  PATHOLOGY.  323 


Literature  of  '96-'97-'98. 

Existence  established  of  an  early  syphi- 
litic cedema  of  the  larynx,  independent 
of  all  ulceration  or  erosion,  and  itself  the 
solitary  notification  that  the  specific 
virus  has  attacked  that  organ.  Lacroix 
(Archives  de  Laryng.,  Nov.  and  Dec, 
'97). 

Acute  cedema  of  the  larynx  in  two 
cases  due  to  iodide  of  potassium:  1.  Case 
of  pulmonary  laryngeal  phthisis.  Five 
days  after  potassium  was  begun  a  con- 
siderable cedema  of  the  left  aryteno- 
epiglottic  fold  was  noticed,  which  disap- 
peared when  the  iodide  was  discontinued. 
2.  Case  in  which  patient  was  given  potas- 
sic  iodide  for  syphilitic  manifestations. 
After  two  weeks  there  was  coryza  and 
dyspnoea  and  cedematous  swelling  on  the 
right  side  of  the  larynx.  The  iodide  was 
omitted,  and  the  swelling  disappeared. 
The  oedema  was  unilateral  in  both  cases, 
a  feature  not  often  met  with  in  cases 
hitherto  recorded.  Stankowski  (Munch, 
med.  Woch.,  Mar.  23,  '97). 

As  the  cause  of  oedema  of  the  larynx 
is  more  thoroughly  studied  the  cases  that 
cannot  be  ascribed  to  either  some  pre- 
existing local  affection  in  either  the 
pharynx  or  the  larynx  or  to  some  consti- 
tutional disease  or  external  irritation 
will  be  exceedingly  rare.  C.  C.  Rice 
(N.  Y.  Med.  Jour.,  Dec.  3,  '98). 

Many  of  the  cases  of  cedema  of  the 
larynx  are  thought  to  be  of  infections 
origin,  exposure  of  the  parts  to  weakening 
influences  of  cold,  etc.,  facilitating  the 
entrance  of  micro-organisms  of  neighbor- 
ing inflammatory  processes,  particularly 
of  the  naso-pharynx.  The  base  of  the 
tongue,  the  mouth,  and  the  tonsils  are 
known  to  be  sources  of  infection. 

Acute  primary  oedema  of  the  larynx  is 
an  infectious  disorder,  streptococci  and 
pneumococci  having  been  found  in  several 
cases  of  that  affection.  Cold  and  trau- 
matisms considered  as  but  occasional 
causes  favoring  the  penetration  of  germs 
into  the  organism.  F.  Bar j  on  (Gaz.  des 
Hop.,  May  19,  '94). 

Case  of  a  man  in  whom,  shortly  after 
removal  of  a  loose  biscuspid  tooth,  cellu- 


litis of  the  face  and  neck  developed. 
(Edema  of  the  pharynx  developed,  and 
afterward  oedema  of  the  larynx.  Lar- 
yngo  -  tracheotomy  performed.  Symes 
(Dublin  Jour.  Med.  Science,  Aug.,  '92). 

Case  of  secondary  oedema  of  the  larynx, 
following  suppuration  of  a  deeply-seated 
gland  in  the  region  of  the  carotid  artery. 
Extirpation  of  the  lymphatic  gland  pro- 
duced immediate  marked  relief.  Addeo 
Totti  (Lo  Sperimentale,  Mar.  15,  '92). 

Inflammatory  disorders  of  the  glands 
of  the  neck,  parotitis,  tonsillitis,  etc.,  may 
thus  suddenly  be  complicated  with 
oedema  of  the  larynx  with  its  attending 
dangers. 

Case  of  sudden  death  probably  from 
oedema  of  the  glottis,  in  a  healthy  lad  17 
years  of  age,  with  unilateral  tonsillitis. 
Francis  Minot  (Boston  Med.  and  Surg. 
Jour.,  Dec,  '90). 

Case  of  cedema  of  the  larynx  resulting 
from  pyaemia,  which  seemed  to  have  fol- 
lowed the  introduction  of  a  sound  to  re- 
lieve a  urethral  stricture  following  gon- 
orrhoea. J.  H.  Bryan  (Med.  News,  Feb. 
6,  '92). 

Burning  or  scalding  of  the  larynx, 
traumatisms, — such  as  those  induced  by 
the  passage  of  foreign  bodies,  sharp 
bones,  tacks, — etc.,  may,  as  stated,  also 
act  as  etiological  factors.  Even  alcohol 
has  been  known  to  produce  localized 
oedema. 

Case  of  cedema  of  the  larynx  reported, 
the  location  of  which  was  not  defined, 
due  to  the  action  of  raw  spirit  poured 
into  a  woman's  mouth  while  she  was  in 
a  state  of  syncope.  The  patient  recovered. 
G.  H.  Darwin  (Brit.  Med.  Jour.,  Jan.  14, 
'88). 

CEdema  of  the  larynx  comprises  all 
cases  in  which  the  oedema  is  a  conse- 
quence of  another  local  or  general  proc- 
ess; no  inflammatory  reaction  is  present; 
the  etiological  factors  include  Bright's 
disease,  cardiac  affections,  venous  stasis, 
anaemia,  and  general  hydrsemia  and 
angioneurotic  processes.  Kuttner  (Vir- 
chow's  Archiv,  Jan.  4,  '95). 

Eecords  of  autopsies  made  under 
charge  of  Virchow,  between  1873  and 


324 


LARYNGITIS.    (EDEMA  OF  THE  LARYNX.  TREATMENT. 


1878,  examined  by  Peltesohn  gave  the 
following  results: — 

In  3887  examinations,  oedema  of  the 
larynx  was  noted  210  times, — 149  in 
men,  40  in  women,  and  21  in  children. 
Forty-four  cases  had  occurred  in  regional 
disease  and  166  in  systemic  disease.  Of 
5161  patients  treated  in  the  clinic  for 
diseases  of  the  throat  and  nose,  between 
April  1,  '87,  and  June  1,  '89,  there  were 
only  8  with  acute  oedema  of  the  larynx, 
— 7  in  men  between  21  and  48  years  of 
age  and  1  in  a  woman  58  years  of  age. 

Prognosis. — (Edema  of  the  larynx  is  at 
times  so  rapidly  fatal  that  no  warning  of 
the  oncoming  issue  is  afforded.  A  pa- 
tient suffering  from  slight  hoarseness  on 
retiring  may  thus  be  found  dead  next 
morning.  Though  such  cases  are  com- 
paratively rare,  they  nevertheless  show 
the  importance  of  promptly  attending  to 
acute  laryngeal  maladies.  When  the 
iodides  are  being  administered  in  con- 
nection with  throat  disorders,  the  larynx 
should  be  frequently  examined  laryn- 
goscopically. 

Cases  in  which  the  infiltration  is  local- 
ized are  obviously  less  likely  to  prove 
mortal  than  those  involving  all  the  tis- 
sues. The  latter  form  is  that  most  fre- 
quently met  with  when  general  disorders 
— such  as  scarlet  fever,  typhoid  fever, 
variola,  etc. — act  as  the  primary  factor. 

Sestier  found  that  the  affection  proved 
fatal  in  158  out  of  213  cases  in  spite  of 
tracheotomy  performed  thirty  times.  In 
the  55  cases  which  recovered  tracheotomy 
was  performed  twenty  times.  Bayle  re- 
ports 17  cases  with  16  deaths.  P.  E.  Hop- 
kins (Med.  Record,  Oct.  19,  '95). 

Treatment  of  (Edema  of  the  Larynx.— 

When  oedema  is  present  vigorous  meas- 
ures should  be  adopted  when  dyspnoea 
becomes  evident.  Until  then,  cracked 
ice  should  be  kept  in  the  mouth  and  cold- 
water  compresses  applied  around  the 
throat.    The  patient  should  be  well  cov- 


ered and  given  a  hot  mustard  foot-bath, 
then  immediately  placed  in  bed,  but  in 
the  sitting  posture,  and  wrapped  in 
blankets — the  object  being  to  cause  nor- 
mal diaphoresis.  If  this  cannot  be  ob- 
tained normally,  pilocarpine  should  be 
given  hypodermically,  or  internally  if 
the  local  manifestations  are  not  marked. 

The  bromides  are  useful  in  reducing 
the  local  infiltration,  and  a  dose  of  20 
grains  in  an  adult,  repeated  as  often  as 
needed,  sometimes  proves  very  effica- 
cious. 

Pilocarpine  injected  hypodermically 
proves  very  efficacious  in  reducing  laryn- 
geal oedema.  Six  drops  of  a  5-per-cent. 
solution  of  the  alkaloid,  repeated  three 
times  at  intervals  of  fifteen  minutes, 
caused  complete  relief  in  the  cases  re- 
ported. Suarez  de  Mendoza  (Revue  de 
Laryng.,  Aug.  15,  '91). 

Application  of  leeches  to  the  front  of 
the  neck  is  very  effective  in  acute  and 
primary  laryngeal  oedema.  Levi  and 
Laurens  (Archiv.  Gen.  de  Med.,  Dec,  '95). 

If  a  case  be  seen  at  the  beginning  of  an 
attack,  the  treatment  consists  of  inhala- 
tion of  warm  medicated  vapor,  the  use 
of  diaphoretics,  the  maintenance  of  the 
patient's  room  at  an  equable  tempera- 
ture (72°  F.).  with  the  air  moistened  by 
the  vapor  of  boiling  water,  and  at  a  later 
stage  the  application  of  leeches  over  the 
region  of  the  larynx,  to  be  followed  by 
the  continuous  use  of  the  cold  coil.  The 
sucking  of  pellets  of  ice  is  also  to  be 
recommended.  Upon  the  appearance  of 
oedema,  however,  scarification  with  the 
laryngeal  lancet  should  be  performed. 
F.  E.  Hopkins  (Med.  Record,  Oct.  19,  '95). 

Literature  of  '96-'97-'98. 

Acute  submucous  laryngitis  in  chil- 
dren, characterized  anatomically  by  sub- 
mucous infiltration,  bearing  a  misleading 
resemblance  to  acute  oedema,  is  mani- 
fested clinically  as  a  suffocative  catarrh. 

A  point  of  particular  diagnostic  im- 
portance is  the  association  of  an  unim- 
paired voice  with  a  hoarse  cough.  In- 
tubation is  indicated  when  retraction  is 
marked.  Castaneda  (Jour,  of  Laryn., 
Rhin..  and  Otol..  Apr.,  '97). 


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LARYNGITIS.    (EDEMA  OF  THE  LARYNX.  TREATMENT. 


325 


In  a  case  of  acute  idiopathic  oedema  of  | 
the  epiglottis  in  a  man  of  41,  a  spray  of 
ichthyol,  V3  per  cent.,  in  ice-water  every 
fifteen  minutes,  with  ice  externally,  gave  j 
rapid  relief.     W.  P.  Meyjes   (Jour,  of 
Laryn.,  etc.,  Mar.,  '97). 

Tincture  of  belladonna,  5  drops  every  j 
hour  until  its  physiological  effects  be-  j 
come  marked,  also  tends  to  counteract 
the  infiltration  by  contracting  the  laryn- 
geal blood-vessels. 

Astringent  solutions  should  only  be 
used  in  circumscribed  oedema,  a  weak  j 
solution  of  tannin,  alumnol,  or  resorein 
being  valuable  in  such  cases.   When  the 
cases  can  be  closely  watched,  a  10-per- 
cent, solution  of  cocaine  applied  directly  j 
to  the  larynx  causes  momentary — though 
slight — retraction  of  the  tissues,  and  may 
thus  be  advantageously  used  especially  | 
when  surgical  measures  are  to  be  resorted 
to:   scarification,  intubation,  or  trache- 
otomy.  In  some  cases,  however,  it  seems 
to  increase  the  dyspnoea. 

When  the  dyspnoea  becomes  urgent, 
scarification  of  the  laryngeal  tumefaction 
is  indicated.    With  the  assistance  of  the  j 
laryngeal  mirror — held  in  the  left  hand 
— the  procedure  is  quite  easy  after  anses-  j 
thetizing  the  laryngeal  tissues  with  a  ! 
10-per-cent.  solution  of  cocaine.  The 
pocket-case  curved  bistoury  is  wrapped 
in  a  piece  of  bandage  held  in  place  with 
thread  up  to  within  an  eighth  of  an  inch 
of  the  tip,  to  prevent  cutting  the  tongue 
with  edge  of  the  blade.    The  tongue  be-  ] 
ing  drawn  out  and  held  by  the  patient, 
the  epiglottis  will  generally  be  seen  stand- 
ing erect,  and  looking,  when  much  infil- 
tration exists,  not  unlike  a  pale  cherry. 
This  should  not  be  punctured  first,  as  the  ' 
patient  may  refuse  a  second  incision  and  I 
the  first  should  be  the  most  profitable 
one  to  him.    The  portion  playing  the 
most  important  part  in  the  production  of 
the  dyspnoea  is  the  aryepiglottic  fold,  and 
this  can  usually  be  depleted  by  means  of  I 


a  short  incision  into  its  external  border, 
thus  causing  the  blood  and  serum  to  flow 
into  the  pyriform  sinus,  instead  of  into 
the  larynx  proper.  When  the  patient  is 
docile,  both  sides  can  be  scarified  and  the 
epiglottis  also,  care  being  taken  to  prick 
the  edges  with  the  point  rather  than  the 
internal  aspect  of  the  laryngeal  walls. 

When  a  laryngoscopic  mirror  is  not  at 
hand,  the  index  finger  of  the  left  hand 
should  be  passed  behind  the  epiglottis 
and  used  as  guide  for  the  curved  bistoury. 

At  times  scarification  even  when  thor- 
oughly carried  out,  does  not  relieve  the 
dyspnoea.  In  that  case  the  lower  portion 
of  the  larynx  and  the  tissues  beneath  the 
vocal  bands  wTill  probably  be  found  in- 
volved in  the  inflammatory  process,  when 
examined  laryngoscopically — if  seen  at 
all.  Under  these  circumstances  either 
intubation  or  tracheotomy  must  be 
resorted  to.  (See  Intubation  and 
Tkacheotomy.) 

In  acute  circumscribed  oedema  of  the 
larynx  scarifications  should  be  made. 
Landgraf  (Jour,  of  Laryn.,  Apr.,  '94). 

In  the  early  stages  of  primary  oedema 
cold  applications  externally,  broken  ice, 
and  tannin;  later  on  hot  fomentations 
should  be  applied  to  the  neck.  The  re- 
spiratory difficulty  often  yields  to  ether 
or  sodium  bromide  with  syrup  of  chloral. 
Insufflation  of  tannin  solution  is  more 
valuable  in  serous  than  inflammatory 
oedema;  in  the  latter  pilocarpine  injec- 
tions are  preferable.  Scarification  con- 
demned. Tracheotomy  preferred  to  in- 
tubation, since  the  passage  of  the  can- 
nula in  the  latter  case  is  often  stopped 
by  the  oedema.  Attention  must  be  paid 
to  the  general  condition.  L.  Bar  (Allg. 
Wien.  med.-Zeit.,  Aug.  11,  18,  25,  '96). 

When  laryngitis  is  due  to  traumatism 
and  the  manifestations  are  not  suffi- 
ciently marked  to  require  operative  meas- 
ures, considerable  pain  is  sometimes 
present:  again,  the  lesion  is  so  exposed 
that  infection  may  occur,  a  benign  proc- 
ess thus  being  transformed  into  a  severe 


326  LARYNGITIS. 

one.  The  most  satisfactory  results  are  to 
be  obtained  by  strict  cleanliness  through 
the  use  of  a  5-grain  solution  of  borax 
applied  with  the  atomizer,  the  laryn- 
goscopical  mirror  being  employed  to 
properly  locate  the  spray.  Two  grains  of 
pure  iodoform  are  then  applied  with  the 
insufflator.  This  reduces  the  pain  and 
curtails  the  infectious  process  in  any 
form  of  laryngitis  in  which  these  ele- 
ments prevail. 

Symptomatic  Laryngitis. 

This  term  is  sometimes  applied  to  the 
laryngeal  manifestations  occurring  in  the 
course  of  general  diseases,  and  involving, 
as  a  rule,  the  deeper  structures.  The 
symptoms  vary  with  the  intensity  of  the 
local  manifestations,  and  may  range  from 
those  of  a  simple  laryngeal  catarrh  to  the 
most  severe  oedema  calling  for  immediate 
tracheotomy.  Complications  of  so  dan- 
gerous a  nature  are  fortunately  rarely 
witnessed. 

Measles  is  usually  attended  by  inflam- 
matory involvement  of  the  larynx.  There 
is  hoarseness  and  sometimes  loss  of  voice, 
the  symptoms,  in  fact,  being  quite  those 
of  acute  laryngitis,  including  occasion- 
ally slight  tumefaction. 

The  laryngoscope  reveals  a  condition 
similar  to  that  of  the  skin,  the  exanthem 
showing  itself  more  or  less  clearly.  Eed 
spots  project  from  the  surface,  giving  it 
an  irregular  appearance.  The  process  of 
resolution  usually  progresses  without 
complication.  Occasionally,  however, 
oedema  or  ulceration  occurs  as  a  compli- 
cation. 

Case  of  acute  laryngitis  in  measles  in 
which  the  vocal  bands  became  completely 
destroyed  by  ulceration,  which  had  ex- 
tended upward  to  the  ventricles  and 
downward  for  nearly  l/t  inch  (6  milli- 
metres), penetrating  apparently  down  to 
the  cartilages.  L.  Emmett  Holt  (Med. 
Record,  June  22,  '89). 

Variola  and  Varicella. — The  laryngeal 


SYMPTOMATIC. 

manifestations  of  variola  are  various.  In 
some  cases  small  pustules  are  observed; 
these  may  gradually  develop  into  a  ne- 
crotic process,  leading  to  perichondritis 
and  even  oedema.  The  symptoms  are 
those  of  acute  laryngitis.  The  intensity 
of  the  local  disorders  varies  with  the 
gravity  of  the  general  disease,  but,  as  a 
rule,  the  course  is  a  benign  one. 

In  varicella  laryngeal  symptoms  are 
not  as  frequently  observed  as  in  variola, 
but  they  sometimes  assume  as  serious 
proportions.  Deglutition,  phonation, 
and  respiration  may  be  seriously  im- 
paired, the  latter  resulting  mainly  from 
the  smallness  of  the  larynx  in  children. 

Literature  of  '96-'97-'98. 

In  varicellous  laryngitis  the  symptoms 
are  those  of  croup.  The  specific  charac- 
ter of  the  disease  is  very  clear,  there  oeing 
small  circular  ulcerations  on  the  vocal 
cords,  and  often  on  the  epiglottis.  Harlez 
(Jour,  de  Med.,  June  25,  '97). 

Autopsy  of  a  case  of  varicellous  laryn- 
gitis in  which  there  was  found  gangrene 
of  the  edge  of  the  epiglottis,  a  strip  of 
slough  on  the  free  borders  of  the  vocal 
cords.  A  crateriform  erosion  on  the 
velamentous  portion  of  the  left  vocal 
cord.  A  varicella-spot  on  the  mucous 
membrane  of  the  left  pyriform  fossa. 
Roger  and  Bayeux  (Presse  Med.,  Apr.  10, 
'97). 

Scarlet  Fever. — In  this  disorder  more 
or  less  marked  involvement  of  larynx  is 
frequent.  In  the  vast  majority  of  cases, 
however,  the  cause  of  the  trouble  is  be- 
nign, and  resolution  occurs  along  with 
the  general  malady.  The  exceptions  in- 
ferred may  at  least  simulate  various  grave 
disorders,  such  as  diphtheria  and  mem- 
branous laryngitis.  (Edematous  infiltra- 
tion is  also  occasionally  witnessed,  and 
likewise  constitutes  a  grave  complication. 
In  all  these  disorders  the  tendency  to 
ulceration  is  markedly  increased,  and, 
when  this  starts,  it  is  checked  with  diffi- 


LARYNGITIS. 

culty.  Perichondritis  and  haemorrhage 
owed  to  destruction  of  blood-vessels  are 
always  to  be  feared  in  such  cases. 

Erysipelas. — There  is  a  form  of  acute 
laryngitis,  closely  associated  with,  if  not 
an  actual  manifestation  of,  erysipelas  of 
the  larynx.  This  is  a  dangerous  form, 
often  accompanied  by  oedema,  high  fever, 
great  hoarseness,  and  dyspnoea  almost 
from  the  start. 

Infectious  phlegmon  of  the  pharynx 
and  the  larynx  should  be  differentiated 
from  erysipelas.  Dysphagia,  albuminu- 
ria, splenic  engorgement,  and  in  many 
instances  delirium  cited  as  the  special 
characteristic  indications  of  the  malady. 
P.  Merklen  (Le  Mercredi  Med.,  Nov.  12, 
'90). 

Typhoid  Fever. — The  laryngeal  com- 
plications of  typhoid  are  to  a  certain  de- 
gree typical  in  the  fact  that  they  are  cir- 
cumscribed in  the  great  majority  of  cases. 
The  parts  that  most  frequently  show 
erosions  are  the  laryngeal  surface  of  the 
epiglottis  near  the  edge,  the  ventricular 
bands,  and  the  upper  part  of  the  aryte- 
noid space,  the  specific  character  of  the 
complication  being  thus  readily  shown. 
The  various  ulcerative  processes  noted  in 
scarlet  fever  are  also  occasionally  ob- 
served in  typhoid  fever,  the  tendency  to 
spread  being  equally  marked.  The  de- 
structive process  may  not  only  present 
itself  during  the  progress  of  the  general 
affection,  but  at  some  time  after. 

The  lesions  may  appear  during  two 
periods  of  the  malady.  In  the  beginning 
laryngitis  is  very  common  and  ordinarily 
benign,  rarely  penetrating  into  the  deeper 
tissues.  It  is  during  convalescence,  two 
months  after  the  commencement  of  the 
malady,  that  a  severe  form  of  laryngitis 
may  be  developed,  a  form  fatal  in  the 
absence  of  prompt  relief  by  tracheotomy, 
and  leaving  deformities  which  necessitate 
the  indefinite  retention  of  the  cannula. 
These  lesions  usually  involve  the  aryt- 
enoid, epiglottic,  and  cricoid  cartilages. 
Peter  (L'Union  Med.,  Mar.  10,  '91). 


SYMPTOMATIC.  327 

Catarrhal  laryngitis,  oedema  of  the 
glottis,  perichondritis,  may  all  be  seen. 
The  last-mentioned  lesion  may  give  rise 
to  most  wide-spread  results  in  the  direc- 
tion of  stenosis,  besides  its  immediate 
dangers  from  necrosis  of  the  cartilages 
and  the  like.  From  the  intense  prostra- 
tion and  apathy  of  the  later  period  of 
typhoid  these  may  go  for  some  time  un- 
noticed and  progress  untreated.  The 
presence  of  Eberth's  bacillus  in  the 
sputum  noted  and  also  in  sections  of  the 
mucous  membrane  of  tlie  larynx  in  a 
fatal  case  or  typhoid,  showing  that  the 
laryngeal  lesion  is  of  a  specific  character, 
and  not  due  simply  to  the  general  effects 
of  the  fever.  The  importance,  in  cases 
of  typhoid  in  which  there  is  any  sus- 
picion of  laryngeal  symptoms,  of  exami- 
nation with  the  laryngoscope  emphasized. 
Lucatello  (Gazzetta  degli  Ospitali,  No. 
132,  '93). 

Literature  of  '96-'97-'98. 

In  post-mortem  records  of  St.  Bartholo- 
mew's Hospital  of  sixty-one  cases  of 
typhoid  fever,  fourteen  showed  loss  of 
substance  in  the  larynx.  The  larynx  had 
not  been  examined;  assuming  that  the 
larynx  had  been  examined  in  all  the  re- 
maining fifty-three  cases,  which  is  doubt- 
ful, ulceration  was  found  in  26  per  cent, 
of  the  fatal  cases.  These  defects  are 
situated  generally  over  the  tip  and  edges 
of  the  epiglottis  and  in  the  neighborhood 
of  the  processus  vocalis.  The  lesions  are 
caused  by  micro-organisms;  there  is  the 
strongest  evidence  that  these  are  the 
pyococci,  and  not,  except  rarely,  the 
typhoid  bacilli.  Kanthack  and  Drysdale 
(Jour,  of  Laryn.,  etc.,  Apr.,  '96). 

When  ulceration  of  the  larynx  is  noted 
in  typhoid  fever  it  is  not  necessarily 
typhoid  in  nature.  The  ulceration  in 
some  of  the  larynges  obtained  at  autop- 
sies of  persons  dead  from  typhoid  fever 
are  found  under  the  microscope  to  be  of 
a  tubercular  nature.  Jobson  Horne 
(Jour,  of  Laryn.,  etc.,  Apr.,  '96). 

Pertussis. — In  whooping-cough  the 
laryngeal  manifestations  are  sometimes 
quite  marked,  but  they  are  not  attended, 
as  in  other  diseases,  by  ulcerative  proc- 
esses.   The  severe  cough  induced  occa- 


328  LARYNGITIS. 

sicmally  causes  marked  congestion  of  the 
interarytenoid  space,  accompanied,  at 
times,  by  extravasation  and  localized 
haemorrhage.  Slight  oedema  is  fre- 
quently observed.  Diphtheria  as  a  com- 
plication has  been  witnessed,  though 
very  rarely.  The  most  annoying  feature 
in  connection  with  the  larynx  is  a  result- 
ing hyperesthesia  of  the  interarytenoid 
space,  which  may  persist  indefinitely,  the 
patient  being  subject  to  exacerbations  of 
coughing  when  using  his  larynx  any 
length  of  time.  A  dry,  warm,  or  dusty 
atmosphere  is  also  likely  to  cause  con- 
siderable inconvenience.  This  sequel  is 
especially  apt  to  occur  in  adults. 

Influenza. — The  laryngeal  complica- 
tions of  influenza  generally  occur  in  the 
cases  in  which  symptoms  affecting  the 
upper  respiratory  tract  are  observed. 
There  is  the  tendency  to  haemorrhage; 
ulceration  is  also  occasionally  observed. 
Spasmodic  cough  is  also  present,  causing 
considerable  distress  to  the  patient  by 
greatly  increasing  the  intensity  of  the 
frontal  cephalalgia.  (Edema  of  the 
larynx  is  occasionally  met  with,  but,  as  a 
rule,  it  does  not  assume  grave  propor- 
tions. 

Three  cases  of  oedema  of  the  larynx 
following  grippal  laryngitis.  Bavachi 
(Gazette  Med.  d'Orient,  June  30,  '91). 

Disease  of  the  upper  air-passages  is  not 
uncommon  coincident! y  with  attacks  of 
influenza.  The  usual  form  is  a  sanguino- 
purulent inflammation  of  the  pharynx, 
frequently  extending  upward  into  the 
.dome  of  the  pharynx  and  nasal  cavities, 
and  downward  into  the  larynx  and 
trachea,  S.  H.  Chapman  (N.  Y.  Med. 
Jour.,  Dec.  10,  '92). 

Laryngeal  manifestations  are  frequent 
in  influenza.  Generally  there  is  simply  a 
catarrhal  inflammation,  but  serious  com- 
plications may  occur, — ulcers,  erosions, 
paralysis,  oedema.  Two  cases  of  oedema 
witnessed  in  the  Necker  Hospital.  The 
oedema  affected  the  arytenoids  and  ven- 
tricular bands,  and  dyspnoea  w  as  marked, 
but  not  so  great  as  to  necessitate  trache- 


SYMPTOMATIC. 

otomy.  Xatier  had  seen  two  cases  of  in- 
fluenza complicated  with  laryngeal 
oedema  of  the  cords,  which  disappeared 
upon  applications  of  nitrate  of  silver. 
Cartaz  (Journal  of  Laryn.,  June,  '93). 

Typhus  Fever. — In  this  disease  the 
manifestations  are  similar  to  those  in 
typhoid  fever  and  the  complications  are 
also  liability  to  ulceration,  oedema,  or 
pseudodiphtheria. 

Case  of  laryngo-typhus.  Beginning 
with  hoarseness  due  to  acute  laryngitis, 
with  ulceration,  dyspnoea  soon  follows, 
demanding  tracheotomy.  If  the  patient 
recover,  the  local  disorder,  perichondritis, 
cricoarytenoid  ankylosis,  etc.,  will  likely 
cause  the  wearing  of  the  cannula  to  be- 
come permanent.  Tissier  and  Bellit 
(Ann.  de  Med.  Therm.,  Dec.  21,  '92). 

S.chech  includes  under  the  name  of 
"laryngitis  exudativa*'  a  series  of  affec- 
tions of  the  laryngeal  mucous  membrane 
in  which  there  is  exudation  with  more  or 
less  fluid  contained  in  vesicles  or  bullae, 
or  hyperemia  with  swelling.  In  miliaria 
there  are  vesicles  on  the  epiglottis  and 
aryepiglottic  folds,  giving  rise  to  the  sen- 
sation of  a  foreign  body.  Herpes  very 
seldom  occurs  alone  in  the  larynx;  there 
is  usually  an  implication  of  skin  or  of 
mucous  membrane. 

Acute  inflammation  of  the  tongue, 
floor  of  the  mouth,  and  larynx  may  lie 
due  to  herpes.  Two  cases  clinically  in- 
distinguishable from  angina  Ludoviei, 
which  after  death  were  found  to  be  asso- 
ciated with,  if  not  due  to,  trichina 
spiralis  and  miliary  tuberculosis,  respec- 
tively. S.  Mackenzie  (Brit.  Med.  Jour., 
May  18,  '94). 

Herpes  of  the  larynx  only  occurs  as  one 
of  the  localizations  of  herpetic  fever;  its 
most  frequent  seat  is  on  the  posterior 
surface  of  the  epiglottis  and  the  region 
of  the  arytenoids.  The  herpetic  vesicles 
are  surrounded  by  an  inflammatory  zone. 
There  is  odynphagia,  dysphonia,  possibly 
dyspnoea.  Brindel  (Revue  de  Laryn., 
d'Otol.,  et  de  Kliin..  Mar.  15,  '95). 

Schech  also  groups  under  the  same 
1  head  foot-and-mouth  disease  (stomatitis 


LARYNGITIS.    CHRONIC.  SYMPTOMS. 


329 


epidemica)  accompanied  by  more  or  less 
constitutional  disturbance  and  by  vesicles 
in  the  larynx,  which  break  down  into 
ulcers;  aphthae,  which  sometimes  occur 
in  the  larynx  in  association  with  aphtha} 
of  the  mouth  or  vulva;  pemphigus,  which 
occasionally  forms  exudative  swellings  in 
the  larynx,  but  the  disease  is  rare  in  this 
organ.  Urticaria  also  occasionally  affects 
the  laryngeal  mucous  membrane,  and  the 
symptoms  depend  upon  its  extent. 
Lichen  ruber  planus  is  more  usually  ob- 
served in  the  mouth  and  fauces  than  in 
the  larynx.  Impetigo  herpetiformis,  ery- 
thema nodosum,  and  erythema  multiforma 
are  rarely  observed  in  the  larynx. 

Pathology. — Symptomatic  laryngitis  is 
ascribed  to  the  penetration  into  the  laryn- 
geal tissues  of  micro-organisms,  espe- 
cially the  streptococcus  pyogenes,  staphy- 
lococci, the  pneumococcus,  and  bacteria 
coli  communse.  The  germs  are  thought 
to  penetrate  the  deeper  structures 
through  minute  abrasions  of  the  surface 
or  by  way  of  the  lymph-channels,  the 
blood,  etc.  Neighboring  inflammatory 
foci  are  especially  prone  to  cause  infec- 
tious disorders  of  the  larynx. 

Four  cases  of  so-called  angina  Ludo- 
vici  examined:  (1)  acute  cellulitis  of  the 
neck  following  tonsillitis  in  which  the 
streptococcus  was  present;  (2)  gingivitis 
due  to  dental  caries  in  which  the  staphy- 
lococcus albus  and  aureus  were  found; 
(3)  cedema  glottidis  and  pneumonia  in 
which  the  pneumococcus  (Fraenkel) 
was  found;  and  (4)  phlegmonous  in- 
flammation in  a  pregnant  woman  who 
aborted  and  died  of  septicaemia;  strepto- 
cocci were  found  in  the  spleen  and  in 
the  tissues  of  the  neck.  Although  bac- 
teriologically  distinct,  yet  the  processes 
were  pathologically  identical.  Kanthack 
(Brit.  Med.  Jour.,  May  18,  '94). 

The  various  forms  of  acute  septic  in- 
flammations of  the  throat  hitherto  de- 
scribed as  acute  oedema  of  the  larynx, 
cedematous  laryngitis,  erysipelas  of  the 
pharynx  and  larynx,  phlegmon  of  the 
pharynx  and  larynx,  and  angina  Ludo- 


vici  are  probably  identical  pathologically, 
and  represent  degrees  varying  in  viru- 
lence of  one  and  the  same  process.  Felix 
Semon  (Jour,  of  Laryn.,  Sept.,  '95). 

Erysipelas  of  the  larynx,  phlegmonous 
pharyngitis,  and  angina  Ludovici  are  so 
similar  that  the  slight  difference  in  their 
starting-point  is  not  a  sufficient  reason 
for  making  a  different  classification  neces- 
sary. De  Havilland  Hall  (Jour,  of 
Laryn.,  Sept.,  '95). 

Much  good  would  result  from  this 
simple  modification  in  the  classification 
of  these  diseases  suggested  by  Semon; 
personal  experience  tends  in  the  same 
direction.  Typical  angina  Ludovici  the 
least  likely  to  be  pathologically  identical 
with  the  rest.  Dundas  Grant  (Jour,  of 
Laryn.,  Sept.,  '95). 

Treatment. — The  treatment  of  symp- 
tomatic laryngitis  does  not  differ  from 
that  of  acute  laryngitis  or  cedema  of  the 
larynx  when  the  local  manifestations  are 
such  as  to  warrant  assimilation  with  these 
disorders.  As  a  rule,  the  laryngeal  mani- 
festations of  infectious  diseases  are  slight, 
but  the  possibility  of  complications  in 
this  direction  should  always  be  borne  in 
mind,  owing  to  the  rapidity  with  which 
they  may  prove  fatal  when  untreated. 

Chronic  Laryngitis. 

Symptoms. — As  a  result  of  frequently 
repeated  attacks  of  acute  laryngitis,  or  of 
continued  exposure  of  the  larynx  to  con- 
ditions capable  of  maintaining  a  pro- 
longed hypersemia  of  the  larynx,  a 
chronic  catarrhal  process  is  developed. 
Exacerbations  of  hoarseness,  a  sensation 
of  rawness  and  heat,  and  the  presence  in 
the  laryngeal  cavity  of  secretions — mu- 
coid or  muco-purulent — giving  rise  to  a 
constant  desire  to  "hem"  constitute  the 
main  symptoms  of  this  condition. 

Chronic  laryngitis  is  most  frequently 
met  with  in  singers.  Hoarseness  in  these 
represents  the  most  important  symptom; 
it  may  be  continuous  or  occur  only  after 
a  few  bars  have  been  sung.    This  is 


330  LARYNGITIS.    CHRONIC.    SYMPTOMS.  ETIOLOGY. 


usually  accompanied  by  a  feeling  of  local 
fatigue,  heat,  and  constriction.  The 
voice  is  usually  lowered  in  pitch  and  may 
be  veiled,  muffled,  or  complete  aphonia 
may  exist.  Pain  is  sometimes  complained 
of.  Cough  provoked  by  sensation  of  itch- 
ing or  pricking  frequently  occurs  as  a 
prominent  symptom.  Slight  haemor- 
rhage and  blood-expectoration  are  occa- 
sionally noted. 

In  some  cases  these  symptoms  present 
themselves  upon  the  least  exposure,  dis- 
appearing after  a  few  days.  As  the  at- 
tacks are  repeated,  however,  they  become 
more  resistant  to  therapeutic  measures, 
and  the  local  disorder  becomes  perma- 
nent symptomatically  as  well  as  patho- 
logically. Hoarseness  is  then  continu- 
ous. Warm  weather,  however,  is  apt  to 
bring  temporary  relief. 

The  laryngoscopical  appearances  vary 
considerably,  and  are  proportionate  to 
the  degree  of  active  inflammation.  The 
evidences  of  local  hyperemia  are  never- 
theless always  present,  and  vary  from  a 
slight  arborescent  and  light  pink  tinge 
suggestive  of  congestion  to  a  bright-red 
hue  indicative  of  violent  inflammation. 
The  epiglottis  is  also  congested,  enlarged 
vessels  coming  over  its  posterior  surface, 
while  the  aryteno-epiglottic  folds  appear 
thickened,  the  tumefaction  involving  the 
entire  larynx  in  marked  cases.  The  sur- 
face is  irregular  and  sometimes  quite 
bosselated.  The  general  redness  is  not 
so  marked  as  in  some  cases  of  acute  laryn- 
gitis; it  is  apt  to  assume  a  brownish  or 
violet  coloration.  The  vocal  bands  are 
also  more  or  less  congested;  the  conges- 
tion may  either  be  limited  to  a  small  por- 
tion of  their  surface  or  involve  their  en- 
tire area.  Small  masses  of  stringy  cream  - 
like  mucous  are  frequently  to  be  seen 
forming  films  when  the  glottis  is  opened. 

Sometimes  the  vocal  bands  appear  re- 
laxed and  their  thickened  edges  do  not 


seem  to  come  accurately  together,  an 
elliptical  opening  being  occasionally  ob- 
served between  them.  This  want  of 
parallelism  is  due  to  muscular  paresis, 
affecting  usually  but  one  side. 

Shallow  abrasions  of  the  epithelial 
covering  are  occasionally  met  with, 
especially  in  the  interarytenoid  space. 
Deeper  ulcerations  sometimes  leading  to 
perichondritis  have  been  observed  by 
various  clinicians. 

The  secretions  are  sometimes  very 
copious,  especially  when,  in  the  latter 
part  of  an  active  exacerbation  of  vocal 
disability,  the  patient  tries  to  use  his 
voice.  This  condition  is  termed  "laryn- 
gorrhcea"  by  some  authors. 

The  terms  "dry  laryngitis"  and  "laryn- 
geal ozcena"  have  been  given  to  a  condi- 
tion occasionally  met  with,  in  which  the 
secretion,  besides  being  muco-purulent, 
is  prone  to  adhere  firmly  to  the  mucous 
surfaces  and  to  become  partly  desiccated 
in  this  situation.  The  dry  crusts  formed, 
by  impeding  the  free  passage  of  air,  give 
rise  to  more  or  less  dyspnoea,  while  the 
breath  is  rendered  foetid.  Laryngoscop- 
icallv  examined,  the  larynx  appears  red 
and  dry,  with  greenish  crusts  closely  ad- 
hering to  parts  adjoining  the  vocal  cords 
either  above  or  below. 

Case  in  which  the  green  secretion  al- 
most occluded  the  tracheal  lumen,  caus- 
ing marked  stridor.  Kuh  (Jour.  Amer. 
Med.  Assoc.,  Apr.  15,  '93). 

Etiology. — In  singers,  officers,  huck- 
sters, etc.,  who  are  called  upon  to  use  the 
voice  excessively,  chronic  laryngitis  may 
occur  as  a  primary  affection,  but  in  per- 
sons who  do  not  use  their  vocal  organs 
professionally,  the  primary  cause  can 
usually  be  traced  to  some  disorder  of  the 
adjoining  cavities,  nasal,  naso-pharyn- 
geal,  and  pharyngeal.  A  dusty  or  smoky 
atmosphere  may  induce  chronic  laryn- 
gitis, but  the  other  portions  of  the  upper 


LARYNGITIS.    CHRONIC.    PATHOLOGY.  TREATMENT. 


331 


respiratory  tract  are  involved  in  the  in- 
flammatory process. 

The  rheumatic  and  gouty  diathesis, 
gastric  and  hepatic  disorders,  the  abuse 
of  alcoholic  beverages,  and  all  the  factors 
enumerated  under  the  heading  of  Acute 
Cataeehal  Laryngitis  may  act  as 
causative  factors  when  exposure  to  them 
is  prolonged. 

Dry  laryngitis  has  been  ascribed  to 
many  affections.  In  some  cases  it  is  but 
a  manifestation  of  a  general  atrophic 
process  involving  the  mucous  membrane 
of  the  upper  respiratory  tract  and  may 
thus  be  identified  through  the  presence 
of  Lowenberg's  bacillus. 

Existence  denied  of  true  pharyngitis 
and  laryngitis  sicca.  In  all  cases  seen  it 
was  combined  with  diseases  of  the  High- 
more  antrum,  with  tubercular  or  syphi- 
litic diseases.  Krebs  (Monats.  f.  Ohrenh., 
Nos.  6,  7,  '95). 

Dry  laryngitis  may  be  primitive  and 
occur  independently  of  any  lesion  of  the 
nasal  pharynx.  It  is  probably  of  a  para- 
sitic nature  and  caused  by  Lowenberg's 
coccus.  Moline  (Jour,  of  Laryn.,  Dec, 
'95). 

In  the  very  few  cases  that  I  have  met 
with,  dry  laryngitis,  when  not  accounted 
for  by  a  naso-pharyngeal  affection  or 
syphilis,  was  found  associated  with  a 
gouty  diathesis.  The  infraglottic  space 
seems  to  be  the  favored  region  for  the 
formation  of  the  greenish  crusts  observed 
in  this  condition. 

"Laryngitis  hiemalis,"  or  winter  lar- 
yngitis, a  variety  of  subacute  laryngitis 
in  which  the  secretions  are  rapidly 
changed  into  adhesive  crusts.  Cold 
weather  is  the  important  factor  in  its 
production.  There  is  complete  aphonia. 
The  crusts  often  cling  to  the  surfaces  of 
the  true  bands  and  the  arytenoids.  The 
evidences  of  inflammation  in  the  larynx 
are  slight.  The  condition  differs  from 
laryngitis  sicca,  which  it  closely  resem- 
bles, how  ever.  Improvement  rapidly  fol-  i 
lows  removal  of  the  crusts  and  the  use  of 
a  spray  containing  vaselin  and  eucalyp-  ' 


tol.  Mulhall  (Med.  Review,  June  17, 
'93). 

Chronic  inflammatory  disorders  of  the 
larynx  are  more  frequently  observed  in 
men  than  in  women,  doubtless  because 
the  former  are  more  exposed  to  the  eti- 
ological factors  outlined  than  the  latter. 
Smoking  and  drinking  is  a  prolific  in- 
direct cause,  as  stated,  and  these  habits 
are  most  generally  indulged  in  by  the 
male  sex.  Chronic  laryngitis  can  occur 
at  all  ages. 

Case  of  chronic  self-inflicted  ulceration 
of  the  throat  by  means  of  nitrate  of  silver 
or  nitric  acid.  F.  Semon  (Med.  Press 
and  Circ,  Jan.  30,  '94). 
Pathology. — Dilatation  of  the  blood- 
vessels, through  paresis  of  the  vaso- 
motors, interstitial  infiltration  which 
may  lead  to  hypertrophy  and  thickening, 
are  the  main  pathological  features  at- 
tending a  case  of  uncomplicated  chronic 
pharyngitis.  The  superficial  vessels  tend 
to  become  varicose,  tortuous  veins  being 
observed,  especially  in  regions — such  as 
the  ventricular  bands,  the  interarytenoid 
membrane,  etc. — where  the  tissues  are 
lax.  The  glandular  elements  take  an 
unusually  active  part  in  the  inflammatory 
process  of  some  cases,  constituting  what 
has  been  termed  a  "glandular  laryngitis." 
Hounded  sessile  projections,  differing 
but  slightly  from  the  neighboring  tissues 
in  color,  have  been  called  "chorditis 
tuberosa"  or  "trachoma  of  the  larynx," 
but  these  are  probably  but  mere  localized 
hypertrophies,  strictly  associated  with 
chronic  laryngitis.  The  tissues  beneath 
the  vocal  bands  often  take  part  in  the 
inflammatory  process. 

Treatment. — The  association  so  fre- 
quently noticed  between  chronic  inflam- 
mation of  the  naso-pharynx  and  of  the 
larynx  renders  it  imperative  always  to 
examine  the  entire  upper  respiratory 
tract  when  continued  hoarseness  is  com- 
plained of.   This  is  further  supported  by 


332 


LARYNGITIS.    CHRONIC.  TREATMENT. 


the  fact  that  cases  are  often  met  with  in 
which  no  benefit  whatever  is  derived 
from  treatment  limited  to  the  larynx 
until  attention  is  given  to  the  naso- 
pharyngeal surfaces.  Cleanliness  of 
these  parts,  in  fact,  may  he  considered  a 
sine  qua  non  of  success  in  90  per  cent,  of 
cases.  The  same  remarks  may  be  ap- 
plied in  connection  with  concomitant 
disorders  of  other  organs. 

In  many  cases  the  laryngeal  inflam- 
matory process  is  sustained  by  disorders 
of  gastric,  hepatic,  and  renal  systems,  all 
of  which  require  close  scrutiny. 

Attacks  of  hoarseness  in  professional 
vocalists  are  often  but  exacerbations 
of  chronic  laryngitis,  a  deficiency  of 
lubrication  of  the  vocal  bands  being 
the  main  local  factor.  This  condition 
may  successfully  be  combated  by  ad- 
ministration every  two  hours  of  10  grains 
of  ammonium  chloride  in  a  tumblerful 
of  water,  and  the  topical  use  of  warm 
sprays  of  a  saturated  solution  of  potas- 
sium chloride  at  the  same  intervals.  The 
doses  are  so  managed  that  the  last  one 
should  be  taken  at  least  about  three  hours 
before  a  performance.  This  avoids  ex- 
posure during  the  subsequent  stage  of 
perspiration.  A  lozenge  containing  10 
grains  of  the  ammonium  chloride  taken 
between  the  acts  is  of  benefit  in  many 
instances. 

The  characteristic  congestion  of  this 
affection,  and  even  the  superficial  ero- 
sions frequently  encountered,  will  often 
yield  to  a  detergent  spray  of  bicarbonate 
of  sodium,  borate  of  sodium,  and  salic- 
}date  of  sodium,  3  grains  of  each  to  the 
ounce  of  water,  applied  copiously  three 
times  a  day  to  the  entire  upper  respira- 
tory tract — the  nose,  the  pharynx,  and 
the  larynx. 

In  stubborn  cases  occurring  in  singers, 
spraying  with  a  2-per-cent.  solution  of 
lactic  acid,  used  frequently,- — eight  to 


ten  times  daily,  - —  recommended.  Hy- 
gienic measures  and  tonics  form  impor- 
tant adjuvants.  Massei  (La  Sem.  Med., 
No.  32,  '94). 
After  cleansing,  even  the  slight  ero- 
sions should  be  touched  with  stronger 
agents.  Solutions  of  nitrate  of  silver  are 
most  effective,  but  demand  considerable 
dexterity  if  laryngeal  spasm  is  to  be 
avoided.  The  laryngeal  forceps  must  be 
used,  its  tip,  covered  with  a  cotton 
pledget,  being  gently  applied  to  the 
mucous  membrane.  Eesorcin  is  an  effect- 
ive agent  in  a  solution  containing  7 
grains  to  the  ounce.  A  20-grain  solution 
of  iodoform  in  benzoinol  is  a  very  effect- 
ive remedy,  but  the  difficulty  of  keeping 
the  atomizer  free  when  benzoinol  is  used 
renders  its  employment  obnoxious  to  the 
patient.  The  infraglottic  region  should 
not  be  overlooked  when  local  applications 
are  made,  the  patient  being  also  directed 
to  inhale  deeply  when  the  atomizer  is 
being  used. 

lodol  might  be  substituted,  but  it  pos- 
sesses irritating  properties  when  used  in 
strong  solutions:  5  grains  to  the  ounce 
is  the  maximum  strength  that  an  in- 
flamed larynx  can  stand  with  benefit. 
Solutions  of  sulphate  of  zinc,  sulphate 
of  copper,  and  alum,  5  grains  to  the 
|  ounce,  may  be  substituted  should  the 
other  agents  recommended  not  be  obtain- 
able. 

Mild  cases,  especially  those  in  which 
there  exists  involvement  of  the  infra- 
glottic  tissues,  are  greatly  benefited  by 
benzoate  of  sodium.  Exacerbations  are 
sometimes  quickly  stopped  with  5-grain 
doses  administered  every  three  hours, 
in  addition  to  the  local  measures  recom- 
mended. 

In  certain  cases  the  vocal  bands  will 
present,  during  an  exacerbation  of  the 
catarrhal  process,  the  greatest  amount 
of  congestion  as  compared  with  other 
parts  of  the  laryngeal  cavity.  Their 


LARYNGITIS.    CHRONIC.  TREATMENT. 


333 


mucous  membrane,  as  stated,  appears 
thickened,  bosselated,  and  very  red  at  the 
edge,  the  voice  being  coarse  and  screechy 
when  an  effort  to  sing  is  made.  This 
form  of  chronic  laryngitis  is  character- 
ized by  frequent  exacerbations,  and 
finally  costs  a  singer  his  voice  unless  he 
stops  singing  for  a  while  and  undergoes 
active  local  treatment.  Labus,  of  Milan, 
proposed  flaying  of  the  vocal  bands  in 
these  cases,  and  obtained  several  satisfac- 
tory results.  After  thoroughly  anaes- 
thetizing the  larynx  he  tore  off  with  a 
sharp  square-tipped  laryngeal  forceps  the 
superficial  layer  of  membrane  of  the  vocal 
bands — a  procedure  followed  by  slight 
haemorrhage,  a  few  days'  aphonia,  and 
final  recovery  of  the  voice.  I  have  sub- 
stituted applications  of  chromic  acid  to 
destroy  the  thickened  mucous  layer,  ob- 
taining equally  satisfactory  results.  Co- 
caine causing  a  copious  flow  of  lubri- 
cating fluid  from  the  lateral  tissues  when 
applied  to  the  larynx  for  a  certain  length 
of  time,  it  is  necessary  to  use  the  acid  as 
soon  as  possible  after  the  application  of 
the  25-per-cent.  solution,  the  strength  it 
is  advisable  to  employ. 

The  chromic  acid,  fused  by  heat  to  the 
end  of  a  covered  probe,  such  as  MacCoy's, 
immediately  before  the  anaesthetic,  is  I 
then  applied  to  the  surface  of  one  of  the 
vocal  bands,  while  the  patient,  having 
been  told  to  make  a  sound,  brings  both 
bands  into  apposition.   This  enables  the 
operator  to  avoid  cauterization  of  their 
edges — an  important  point  in  the  preser- 
vation of  the  voice,  especially  in  women,  j 
But  little  if  any  disturbance  follows,  and 
after  a  few  days  hardly  a  trace  remains  of 
the  cauterization,  except  a  spot  present-  ! 
ing  less  redness  than  the  surrounding 
parts.   The  applications  should  be  made  s 
twice  a  week  until  all  traces  of  localized  j 
congestion  or  bosselated  areas  have  dis- 
appeared. 


When  laryngitis  is  aggravated  by  gas- 
tric, hepatic,  or  intestinal  disorder,  espe- 
cially in  drinkers  and  smokers,  attention 
to  these  conditions  should,  of  course, 
form  an  important  part  of  the  treatment. 
In  patients  who  smoke  considerably  the 
congestion  is  often  maintained  simply 
by  the  irritating  action  of  the  air  con- 
taminated with  smoke.  Sitting  in  a 
smoking-car  or  in  a  room  in  which  others 
are  smoking  is,  therefore,  as  bad  as  if 
the  patient  himself  were  smoking. 

In  dry  laryngitis,  attention  to  the 
naso-pharyngeal  disorder  also  forms  an 
important  part  of  the  treatment.  Deter- 
gent and  disinfecting  sprays  are  of  great 
use,  but  must  be  employed  for  a  consider- 
able time.  Chlorate  of  potassium  in  the 
form  of  a  saturated  solution,  and  per- 
manganate of  potassium,  3  grains  to  the 
ounce,  are  effective  agents,  while  listerin 
and  water,  equal  parts,  may  also  be 
recommended,  to  alternate  with  either. 
Iodide  of  potassium,  administered  inter- 
nally, 5  grains  three  times  a  day  in  half 
a  glassful  of  water,  tends  to  increase  the 
laryngeal  secretions,  as  it  does  those  of 
the  nasal  cavities,  especially  in  persons 
who  are  sensitive  to  its  physiological 
effects.  When  a  gouty  or  rheumatic 
diathesis  can  be  traced,  colchicine  or  sa- 
licylate of  sodium  are  indicated.  (See 
Gout  and  Kheumatism.) 

Chaeles  E.  de  M.  Sajous, 

Philadelphia. 

LARYNGOTOMY,  LARYNGECTOMY, 
ETC.    See  Stenosis  of  Aie-passages. 

LARYNX,  FRACTURE  OF.  See 

Fractures. 

LARYNX,  SYPHILIS  OF.  See  Syph- 
ilis. 

LARYNX,  TUBERCULOSIS  OF.  See 

Tuberculosis. 


334 


LEAD.    PHYSIOLOGICAL  ACTION.    ACUTE  POISONING. 


LARYNX,  TUMORS  OF.  See  Tumors. 

LEAD. — Lead  (plumbum)  is  not  offi- 
cial, as  it  is  not  employed  in  medicine. 
Lead  combines  with  oxygen  forming  ox- 
ides, one  of  which  (the  yellow)  is  official 
(plumbi  oxidum,  U.  S.  P.),  with  the  acids 
and  with  chlorine,  iodine,  bromine,  etc., 
forming  salts.  Of  these  salts  the  acetate 
is  the  only  one  used  internally  to  any 
extent,  although  the  iodide  is  rarely  used 
for  alterative  purposes.  The  acetate  of 
lead  (sugar  of  lead)  occurs  in  efflorescent, 
colorless,  shining  transparent  prisms,  or 
flat  crystals,  having  an  acetous  color  and 
a  sweet,  metallic  taste.  It  is  soluble  in 
2  1/3  parts  of  cold,  and  in  1/2  part  of 
boiling  water;  in  21  parts  of  cold,  and 
1  part  of  boiling  alcohol;  in  3  parts  of 
chloroform,  and  in  5  parts  of  glycerin. 

Carbonate  of  lead  (white  lead,  or 
ceruse)  occurs  in  perfectly-white  masses 
or  powder.  It  is  insoluble  in  water,  but 
soluble  in  acetic  acid  and  dilute  nitric 
acid. 

Iodide  of  lead  occurs  in  a  golden- 
yellow  powder  and  is  insoluble  in  cold 
water,  but  soluble  in  200  parts  of  boil- 
ing water  and  in  solution  of  the  alkalies 
and  of  the  iodide  of  potassium. 

Nitrate  of  lead  occurs  in  white  crys- 
tals, and  is  soluble  in  2  parts  of  water. 

Oxide  of  lead  (litharge)  occurs  in  a 
yellow  to  yellow-red  powder  and  is  in- 
soluble in  water,  but  soluble  in  acetic 
and  nitric  acids. 

The  above  salts  and  their  preparations 
are  the  only  ones  official  in  the  United 
States  Pharmacopn'in. 

Preparations  and  Doses. — Plumbi  ace- 
tatis,  1  to  5  grains. 

Plumbi  iodidum,  1/4  to  2  grains. 

Liquor  plumbi  subacetatis. 

Ceratum  plumbi  subacetatis. 

Liquor  plumbi  subacetatis  dil. 

Plumbi  carbonas  (used  externally). 


Unguentum  plumbi  carbonatis. 
Unguentum  plumbi  iodidi. 
Plumbi  nitratis  (used  externally). 
Plumbi  oxidum  (used  externally). 
Emplastrum  plumbi. 
Emplastrum  resinae. 
Emplastrum  saponis. 
Unguentum  diachylon. 

Physiological  Action. — Unless  a  con- 
centrated solution  be  used,  lead  applied 
locally  acts  as  an  astringent  by  inducing 
contraction  of  the  capillaries.  Hence  its 
beneficial  actions  in  inflammation.  Con- 
centrated solutions  are  irritating,  on  the 
contrary,  and  may  induce  inflammation. 

Taken  internally  in  therapeutic  doses, 
lead  also  acts  as  an  astringent,  and  di- 
minishes the  secretions  of  the  gastroin- 
testinal tract.  Beyond  these  effects  the 
manifestations  are  those  of  poisoning. 
The  nitrate,  the  subacetate,  and  the  ace- 
tate are  poisonous  in  the  order  named. 

Acute  Lead  Poisoning. — Acute  poison- 
ing is  rare,  but  may  occur  when  a  soluble 
salt  (notably  the  acetate)  is  taken  in 
poisonous  amounts  (not  less  than  1  ounce 
is  necessary  to  produce  serious  effects). 
The  symptoms  are  a  sweet,  metallic  taste 
in  the  mouth,  pain  in  the  epigastrium, 
and  vomiting  of  white  milky-looking 
liquids,  or  white  curds,  mixed  with  food 
if  any  food  was  present  in  the  stomach. 
The  white  color  indicates  the  presence 
of  chloride  of  lead,  formed  by  the  action 
of  the  hydrochloric  acid  of  the  gastric 
juice.  Later,  irritation  of  the  intestinal 
tract  occurs  with  an  increase  of  pain,  and 
either  diarrhoea  due  to  gastro-enteritis 
or,  in  some  cases,  obstinate  constipation 
is  noticed.  The  stools  are  generally 
black  in  color  (from  the  action  of  the 
intestinal  sulphuretted  hydrogen-gas, 
which  forms  a  sulphide).  The  pulse  be- 
comes rapid  and  tense,  but  later  weak 
and  compressible.    The  face  is  anxious 


LEAD.    CHRONIC  POISONING. 


335 


and  may  be  either  pale  or  lived.  Excess- 
ive thirst  is  present,  with  cramps  in  the 
calves  of  the  legs  or  muscular  twitchings. 
In  fatal  cases  coma,  epileptic  spasms,  or 
collapse  ensues.  Up  to  the  point  of  the 
affection  of  the  nerve-centres  (spasm, 
coma,  or  collapse)  the  prognosis  is  good; 
beyond  this  it  is  unfavorable. 

Treatment  of  Acute  Poisoning  by  Lead. 
— If  there  is  reason  to  believe  that  any 
of  the  lead-salt  is  present  in  the  stomach, 
the  stomach-siphon  may  be  used.  Any 
soluble  sulphate  (Epsom  or  Glauber's 
salts)  will  decompose  the  lead  salt  and 
form  an  insoluble  sulphate  of  lead;  if 
used  in  excess  the  salts  mentioned  will 
act  as  purges  and  wash  out  the  offending 
matter.  Cramp  and  spasms  may  be  re- 
lieved by  hot  applications  to  the  ab- 
domen and  to  the  extremities.  Pain  may 
be  relieved  by  opiates. 

Chronic  Lead  Poisoning. — The  sources 
of  poisoning  by  lead  are  very  numerous. 
Occupations  in  which  lead  is  employed, 
however,  predominate  as  causative  fac- 
tors, and  painters,  white-lead-paint  mix- 
ers or  grinders,  wall  and  other  paper-mill 
operators,  glaziers,  etc.,  are  the  victims 
in  the  great  majority  of  cases. 

Adulterated  foods  and  liquids  repre- 
sent the  main  sources  of  poisoning 
among  those  whose  occupations  do  not 
involve  exposure.  Cooking  utensils 
painted  white  inside,  bread  made  of 
flour  contaminated  with  a  lead-filled 
grind-stone,  cake  colored  with  lead  bi- 
chromate to  avoid  the  use  of  eggs,  im- 
perfectly burnt  pottery,  fruit-jars  glazed 
with  lead,  etc.,  are  as  many  media 
through  which  lead  can  reach  the  sys- 
tem. A  fruitful  cause  of  poisoning  is 
pure  water  when  conveyed  through  lead 
pipes,  the  lead  being  slowly  dissolved. 
When,  however,  the  water  contains  even 
a  minute  quantity  of  lime-salts,  an  in- 
soluble coating  is  formed  which  arrests 


all  further  action  as  soon  as  the  inside 
of  the  pipes  is  completely  covered.  Cos- 
metics, hair-dyes,  and  face-powders  occa- 
sionally cause  plumbism. 

Constitutional  Effects.  —  Slow  absorp- 
tion of  lead,  whether  due  to  industrial, 
accidental,  or  criminal  causes,  mainly  af- 
fects the  muscles,  the  peripheral  nerves, 
the  liver,  and  the  kidneys.  Pallor  of 
muscles  and  mucous  membranes  is  an 
early  result,  fibrosis  occurring  in  ad- 
vanced cases,  accompanied  by  degenera- 
tive changes  in  the  nerve-endings.  These 
changes  become  less  marked  as  the  spinal 
centres  are  approached,  the  spinal  cord 
being  usually  normal.  The  brain,  how- 
ever, is  not  so  exempt  from  morbid 
changes.  All  the  manifestations  of  sat- 
urnine toxaemia  are  pathologically  based 
upon  the  changes  here  outlined. 

A  blue  line  along  the  margin  of  the 
gums,  at  the  base  of  the  teeth,  is  an  im- 
portant sign.  It  is  especially  marked  in 
persons  who  are  not  cleanly  as  regards 
their  mouth. 

Lead  Colic.  —  This  symptom  is  most 
frequently  met  with  in  painters  who  mix 
and  use  white  lead.  The  abdominal 
cramp  is  usually  very  severe,  the  muscles 
being  rigid  and  contracted.  A  peculiar- 
ity of  the  pain  is  the  fact  that  the  loca- 
tion of  its  greatest  intensity  is  around 
the  navel.  It  occurs  by  exacerbations, 
the  accesses  being  often  accompanied  by 
nausea  or  vomiting.  The  tongue  is  white 
and  contracted  and  there  is  thirst  — 
sometimes  intense.  Constipation  is  the 
rule.   The  face  is  pale  or  jaundiced. 

After  continuing  for  a  period  varying 
from  a  few  hours  to  several  days,  the 
symptoms  gradually  recede  and  the  ac- 
cess ceases.  When  no  treatment  is  re- 
sorted to  and  the  causative  occupation  is 
continued,  the  attacks  return  frequently, 
and  death  may  finally  occur  through 
cachexia  or  anaemia,  paralysis  of  the  re- 


336 


LEAD.    CHRONIC  POISONING.  THERAPEUTICS. 


spiratory  muscles,  cirrhosis  of  the  liver, 
or  through  some  intercurrent  disorder. 

Lead  Encephalopathy. — In  some  cases 
marked  cerebral  symptoms  occur.  These 
may  develop  gradually  or  quite  suddenly, 
violent  headache,  vertigo,  tinnitus,  stra- 
bismus, and  other  cerebral  manifesta- 
tions presenting  themselves.  In  the 
cases  developing  slowly  the  symptoms 
tend  to  demonstrate  paresis  of  carious 
systems,  central  and  peripheral,  the  most 
characteristic  of  these  being  wrist-drop, 
due  to  paralysis  of  the  extensor  muscles 
of  the  forearm.  Vertigo,  loss  of  memory, 
disturbances  of  the  special  senses,  cere- 
bral palsies,  hemiplegia,  and  monoplegia 
have  also  been  noted.  Alteration  of  the 
brain-structure,  its  arteries  and  menin- 
ges, is  usually  found  post-mortem. 

Convulsions,  amaurosis,  delirium,  and 
coma,  or  a  condition  simulating  epileptic 
fits,  hallucinations,  mania,  melancholia 
and  hysteria  are  not  infrequently  met 
with.  Saturnine  epilepsy  is  a  dangerous 
manifestation  and  usually  ends  in  death. 

General  Disorders  due  to  Lead. — Lead 
may  act  as  an  etiological  factor  in  many 
diseases.  Its  role  as  such  is  fully  con- 
sidered in  the  articles  upon  the  various 
affections,  and  do  not  require  repetition 
here. 

Treatment  of  Chronic  Poisoning. — The 
indications  are  to  remove  the  causes,  to 
remove  the  poison  already  in  the  body, 
and  to  treat  the  lesions  or  tissue-changes 
produced  by  the  poison.  Frequent  doses 
of  Epsom  salts  will  not  only  relieve  the 
colic,  but  will  convert  any  lead  present 
in  the  gastro-intestinal  tract  into  an  in- 
soluble sulphate,  and  expel  it  from  the 
body.  Jalap  and  calomel,  guarded  with 
opium  to  prevent  griping,  and  alum  in 
2-grain  doses  with  opium  or  morphine, 
are  suggested  as  valuable  remedies. 
When  cerebritis  is  present  a  blister  may 
be  applied  to  the  nape  of  the  neck,  and 


revulsions,  amyl-nitrite,  and  sweating 
(by  pilocarpine)  may  be  tried.  To  elim- 
inate the  lead  our  sheet-anchor  is  the 
iodide  of  potassium,  given  in  doses  of 
10  to  20  grains  three  times  daily.  A 
double  soluble  salt  (potassic  iodide  of 
lead)  is  formed,  which  may  be  excreted 
by  the  kidneys  through  the  urine  and  by 
the  liver  through  the  bile.  Paralysis  is 
an  indication  for  the  exhibition  of 
strychnine  in  large  doses,  during  treat- 
ment with  potassium  iodide  (given  sep- 
arately), and  the  employment  of  massage 
and  electricity.  The  induced  (faradic) 
current  should  be  employed  if  the  mus- 
cles react;  if  they  do  not,  galvanic  cur- 
rent is  indicated.  When  no  reaction  to 
the  direct  (constant  or  galvanic)  current 
is  observed,  the  paralysis  is  seldom  recov- 
ered from.  In  all  cases  removal  from 
the  source  of  poisoning  should  be  in- 
sisted upon. 

Therapeutics. — Lead  is  never  given  to 
affect  the  system  at  large;  the  constitu- 
tional effects  are  of  no  use  in  medicine. 
It  is  used  only  for  the  local  effects, — 
astringency,  etc., — which  differ  with  the 
form  used. 

GrASTR O-I XTESTIXAL  DISORDERS.  

Acetate  of  lead  is  an  astringent  remedy 
often  used  to  arrest  hsematemesis,  espe- 
cially when  due  to  gastric  ulcer.  It  is 
also  recommended  in  chronic  gastritis 
with  pyrosis  and  gastralgia.  In  diar- 
rhoea of  phthisis,  choleraic  diarrhoea, 
and  in  summer  diarrhoea  a  few  grains  of 
the  acetate  with  a  small  dose  of  opium 
or  morphine  relieves  speedily.  In  acute 
and  chronic  dysentery  an  enema  of  4 
grains  of  the  acetate,  1/2  grain  of  mor- 
phine acetate,  and  1  ounce  of  warm  water 
will  relieve  the  tenesmus  and  reduce  the 
frequency  of  the  stools. 

In  cholera  and  the  purging  from  dys- 
entery and  typhoid  fever  a  few  grains  of 
the  acetate  may  be  combined  with  starch 


LEAD. 


LENS,  DISEASES  OF. 


337 


and  a  moderate  dose  of  opium,  and  be 
given  in  enema.  The  acetate  may  also 
be  combined  with  opium  in  suppository 
for  checking  various  forms  of  diarrhoea 
and  for  the  relief  of  irritable  conditions 
of  the  rectum. 

External  Applications  of  Lead. — 
An  excellent  application  to  burns  is 
white-lead  paint  (carbonate  of  lead  and 
linseed-oil),  especially  if  the  surface  is 
not  very  large  and  there  are  no  fears  of 
a  dangerous  amount  of  absorption.  The 
official  ointment  of  the  carbonate  of  lead 
may  be  preferred. 

Lead  lotion  (liquor  plumbi  subace- 
tatis),  diluted  with  3  or  4  parts  of  water, 
is  a  good  application  to  eczema,  where 
there  is  much  weeping.  It  is  also  val- 
uable when  combined  with  laudanum 
(lead-water,  4  parts;  laudanum,  1  part; 
water,  16  parts)  as  an  application  to  in- 
flamed surfaces,  bruises,  sprains,  fract- 
ures, blisters,  scalds,  excoriations,  and 
fissured  nipples. 

The  acetate  of  lead  is  also  an  excellent 
application  for  the  dermatitis  produced 
by  poison-ivy  (Rhus  toxicodendron),  as 
the  lead  precipitates  the  non-valuable 
oil  of  the  poison.  For  this  latter  pur- 
pose Hare  advises  that  8  grains  of  lead 
acetate  should  be  dissolved  in  a  pint  of 
alcohol  and  used  as  a  wash;  cooling 
applications  should  follow,  but  ointments 
should  be  avoided,  as  they  dissolve  the 
poisonous  oil  and  spread  the  irritation. 

Lead  acetate  is  a  useful  application. 
In  pruritus  pudendi  the  lead-water,  or 
cerate,  may  be  used.  Helva  recommends 
the  application  of  equal  parts  of  lead 
plaster  and  linseed-oil  for  sweating,  feet. 
They  should  be  applied  on  linen  and 
wrapped  around  the  feet  every  third  day. 
Nitrate  of  lead  is  used,  in  powder,  in  the 
treatment  of  onychia. 

In  gonorrhoea  and  leucorrhoea  a  solu- 
tion of  lead  acetate  (3  or  4  grains  to  the 


ounce  of  water)  may  be  used  as  an  in- 
jection. Lead  preparations  should  never 
be  used  in  eye-lotions,  as  they  are  apt 
to  deposit  the  lead  in  the  tissues  of 
the  cornea  and  leave  permanent  white 
patches,  especially  if  ulcer  of  the  cornea 
is  present. 
•  C.  Sumner  Witherstine, 

Philadelphia. 

LENS,  DISEASES  OF. 

Anomalies  of  Position. — Anomalies  of 
position  are  always  the  result  of  changes 
in  the  zonula  of  Zinn. 

Classification. — Cases  of  dislocation  of 
the  lens  are  commonly  divided  into  two 
groups:  in  one  of  which  the  lens  has 
completely  left  the  fossa  patellaris  (luxa- 
tion, or  complete  dislocation),  while  in 
the  other  it  still  remains  partly  within 
this  cavity  (subluxation,  or  partial  dis- 
location); but  as  it  is  usually  only  a 
matter  of  time  for  cases  in  the  latter 
group  to  find  their  way  into  the  former, 
this  distinction  only  marks  a  stage  in  the 
history  of  the  case. 

A  more  convenient  and  comprehensive 
classification  can  be  made  on  an  etiolog- 
ical basis. 

Dislocations  of  the  lens  are  either  con- 
genital (ectopia  lentis)  or  acquired. 

The  latter  group  may  be  thus  di- 
vided:— 

1.  Traumatic  cases,  in  which  the 
lesion  varies  in  degree:  (a)  There  may  be 
a  partial  displacement,  the  lens  being 
caused  to  rotate  on  its  axis,  or  pushed 
sideways,  thus  assuming  an  oblique  posi- 
tion, or  a  position  with  its  edge  in  the 
pupil;  or  it  may  be  displaced  sideways 
and  rotated,  (b)  It  may  be  completely 
dislocated  into  the  anterior  chamber. 
(c)  It  may  be  completely  dislocated  into 
the  vitreous  chamber,  (d)  It  may  pass 
through  a  rent  in  the  sclerotic,  and  lie 
under  the  unbroken  conjunctiva:  sub- 


4—22 


338 


LENS,  DISEASES  OF. 


conjunctival  dislocation,  (e)  It  may  pass 
through  a  rent  in  the  conjunctiva.  (/) 
It  has  been  found  beneath  Tenon's  cap- 
sule. 

2.  The  lens  may  escape  from  the  eye 
at  the  moment  of  rupture  of  the  floor  of  a 
large  corneal  ulcer:  a  more  common  in- 
cident in  the  cases  of  ophthalmia  neona- 
torum than  in  any  other  form  of  disease. 

3.  It  may  be  dragged  out  of  position 
by  iridic  adhesions  when  the  iris  is 
stretched  or  rendered  tense  by  the  occur- 
rence of  peripheral  staphyloma. 

4.  It  may  be  pushed  out  of  position  by 
intra-ocular  tumors, 

5.  Its  displacement  may  be  spontane- 
ous. , 

Ectopia  lentis  seems  to  depend  upon 
imperfect  or  incomplete  development  of 
the  zonula,  and,  as  this  developmental 
failure  occurs  especially  along  the  line 
where  closure  of  the  ocular  fissure  takes 
place,  the  more  perfectly  developed 
fibres  at  the  upper  part  drag  the  lens 
in  their  direction.  Consequently  con- 
genital displacements  are  almost  always 
directly  or  obliquely  upward.  They  are 
also  usually  symmetrical,  and  are  not  in- 
frequently accompanied  by  coloboma  of 
the  lens,  which,  moreover,  is  apt  to  be 
undersized  and  thicker  than  normal. 

In  accordance  with  the  above  theory, 
dislocation  of  the  lens  is  occasionally  as- 
sociated with  coloboma  of  the  iris,  ciliary 
body,  and  choroid. 

Two  cases  of  spontaneous  dislocation 
of  the  lens.  Although  produced  by  dif- 
ferent mechanism,  the  two  accidents  were 
due  to  a  like  cause, — a  previous  altera 
tion  of  the  zonula.  Fage  (Jour,  de  MM. 
de  Bourdeaux,  Feb.  1G,  '90). 

Case  of  double  congenital  dislocation 
of  the  lens  in  a  boy  7  years  of  age,  who 
was  also  partially  amblyopic.  The  lens 
in  each  eye  was  tilted  upward,  slightly 
backward,  and  inward.  No  other  struct- 
ural changes  could  be  detected.  Conclu- 
sions that:    (1)  congenital  ectopia  lentis  | 


is  usually  double  ;  (2)  it  is  a  congenital 
malformation,  the  cause  of  which  is  not 
yet  positively  established ;  (3)  amblyopia 
and  ametropia  are  always  concomitant 
conditions,  and  that  the  majority  of 
cases,  so  far  reported,  sustain  the  theory 
of  heredity  as  the  primary  cause.  Friebis 
(Jour.  Amer.  Med.  Assoc.,  Sept.  3,  '92). 

Literature  of  '96-'97-'98. 

Series  of  lenses,  8  in  number,  in  which 
the  nucleus  was  not  central,  but  lay  close 
to  the  posterior  capsule,  either  at  the 
posterior  pole  or  between  it  and  the 
equator.  In  all  the  anomaly  must  have 
been  due  to  a  developmental  disturbance. 
In  some  the  outline  of  the  lens  was  nor- 
mal ;  in  5  others  there  was  a  posterior 
lenticonus.  In  3  of  these  latter  the  con- 
ical ectasia  of  the  lens- surface  was  formed 
by  the  displaced  lens-nucleus,  which  was 
actually  in  contact  with  the  capsule;  in 
the  other  2  this  was  not  the  case,  the 
lens-fibres  lying  quite  regularly  on  the 
little  cone.  The  anterior  section  of  the 
lens  was  in  all  cases  normal.  Only  in  1 
case  did  the  lens-capsule,  much  thinned, 
cover  the  lenticonus.  C.  Hess  ("Bericht 
der  Ophthal.  Gesell.,"  Heidelberg,  '96). 

Dislocation  of  the  lenses  observed  in 
five  children  of  a  family  of  seven  whose 
mother  was  similarly  affected.  In  none 
of  the  cases  was  the  dislocation  upward. 
Miles  (Annals  of  Ophth.,  Otol.,  and  Lar., 
July,  '96). 

Five  cases  of  congenital  bilateral  dislo- 
cation of  the  crystalline  lens  in  three  suc- 
cessive generations.  In  all  the  disloca- 
tion was  upward  or  upward  and  outward. 
E.  T.  Parker  (Phila.  Med.  Jour.,  July  10, 
'98). 

A  case  is  on  record  in  which  the  colo- 
boma of  the  iris  was  upward,  there  being 
a  subluxation  of  the  lens  downward. 

Although  at  first  partial,  congenitnl 
dislocation  often  becomes  complete, 
through  degeneration  and  stretching  of 
the  fibres  of  the  zonula:  the  lens  then 
becomes  movable  to  a  degree  which 
varies  greatly,  not  only  in  the  vitreous 
humor  itself,  but  it  may  even  pass  back- 
ward and  forward  through  the  pupil:  a 


LENS,  DISEASES  OF. 


339 


condition  described  by  Heyman  under 
the  title  of  "spontaneous  motility  of  the 
lens." 

So  long  as  a  congenital  dislocation  of 
the  lens  remains  incomplete,  there  is  no 
special  tendency  toward  the  formation  of 
cataract;  but  when  it  becomes  complete, 
and  freely  movable  in  the  eye,  the  im- 
pairment of  nutrition  thereby  involved 
leads  more  or  less  rapidly  to  its  opacifica- 
tion. Occasionally  a  lens  dislocated  into 
the  vitreous  will  remain  clear  for  years. 

Of  all  cases  of  dislocation  of  the  lens, 
those  of  traumatic  origin  are,  by  far,  the 
commonest.  The  traumatism  usually 
consists  of  a  blow  by  a  blunt  instrument, 
such  as  the  fist  or  a  stone,  upon  the  eye- 
ball; but  concussion  from  a  blow  upon 
the  side  of  the  head  may  have  the  same 
result.  Dislocation  is  more  apt  to  occur 
when  the  vitreous  is  fluid:  a  condition 
which  may  be  accompanied  by  degener- 
ative changes  in  the  zonula,  in  old  age, 
and  in  sclerectasia  anterior. 

Traumatic  luxation  of  the  lens  into  the 
anterior  chamber  usually  occurs  when  the 
patient  is  bent  forward,  the  centre  of  the 
cornea  being  struck  at  that  time.  When 
the  blow  is  nearer  the  periphery  the  lux- 
ation takes  place  in  the  direction  of  the 
force  applied.  Dujardin  (Jour,  des  Sci- 
ences Med.  de  Lille,  Nov.  13,  '91). 

Traumatic  dislocations  present  every 
variety  and  degree,  from  the  slightest 
lateral  displacement  or  rotation  to  com- 
plete expulsion  of  the  lens  from  the  eye- 
ball. 

Lens  in  an  eye  removed  on  account  of 
a  penetrating  wound  found  to  be  dislo- 
cated between  the  ocular  conjunctiva  and 
the  sclera,  where  it  had  become  incapsu- 
lated  in  a  mass  of  inflammatory  exudate. 
Wescott  (Annals  of  Ophthal.  and  Otol., 
Jan.,  '93). 

Two  instances  of  traumatic  dislocation 
of  the  lens  into  the  vitreous,  occurring  in 
individuals  both  of  whom  had  met  with 
a  similar  accident  in  the  opposite  eye 


some  years  previously.  Noyes  (1ST.  Y. 
Eye  and  Ear  Infirmary  Reports,  '94). 

The  traumatism  that  is  the  immedi- 
ate occasion  of  the  displacement  is  often 
the  cause  of  other  ocular  lesions,  which 
may,  for  a  time,  obscure  the  diagnosis, 
and  render  prognosis  more  uncertain 
than  would  otherwise  be  the  case.  The 
dislocation  of  the  lens  may,  indeed,  be 
by  no  means  the  most  important  lesion 
produced.  It  is  common  to  find  haemor- 
rhage in  the  anterior  chamber  immedi- 
ately after  the  injury,  the  full  extent  of 
which  cannot  be  ascertained  until  ab- 
sorption has  taken  place:  or  we  may  find 
dilatation  and  immobility  of  the  pupil, 
haemorrhage  into  the  vitreous,  or  rupture 
of  the  choroid,  and — especially  in  myopic 
eyes — detachment  of  the  retina.  In 
greater  degree  of  violence  the  eyeball 
may  be  ruptured,  usually  in  the  sclera 
just  behind  and  concentrically  with  the 
sclero-corneal  junction,  and  through  this 
rupture  the  lens — with  the  iris,  choroid, 
retina,  and  vitreous — may  escape. 

Case  of  traumatic  dislocation  of  the 
lens,  followed  by  symptoms  of  fulmi- 
nating glaucoma.  Patient  made  a  good 
recovery  after  extraction  of  the  lens. 
Saunders  (Brit.  Med.  Jour.,  Mar.  2,  '89). 

Absorption  of  a  crystalline  lens  that 
had  been  luxated  into  the  vitreous  during 
an  operation  upon  the  eye  for  glaucoma. 
Case  occurred  in  a  boy.  All  children  have 
remarkable  tolerance  for  that  which 
would  cause  glaucoma  in  adult  eyes. 
Chacon  (Gaceta  Med.  de  Mexico,  June  1, 
'92). 

Spontaneous  dislocation  of  the  lens 
may  take  place  wThile  its  transparency  re- 
mains unimpaired,  but  it  seems  to  occur 
more  commonly  when  the  lens  has  be- 
come cataractous,  and  more  especially 
when  the  cataract  has  been  allowed  to 
progress  to  a  condition  of  hypermaturity 
(Morganian  cataract).  Although  in  some 
cases  the  displacement  occurs  without 
any  evident  immediate  exciting  cause,  in 


340  LENS,  DISEASES 

many  the  acts  of  coughing  or  sneezing 
determine  it.  Gunn  in  1895  reported  a 
case  of  quite  spontaneous  symmetrical 
displacement  of  the  lenses  in  a  man  aged 
76.  Three  months  before-  it  failed  a  re- 
corded examination  showed  vision,  with 
refraction  corrected,  to  be  6/6  in  eacn 
eye.  Three  months  after  failure  both 
lenses  were  found  displaced  downward, 
their  upper  edges  being  visible  just 
within  the  margin  of  the  dilated  pupil, 
one  lens  still  remaining  clear,  the  other 
having  become  opaque.  Corrected  vision 
in  each  eye,  6/6.  Fundus  normal.  It  is 
hardly  necessary  to  point  out  that  old  age 
constitutes  the  main  predisposition  to 
spontaneous  dislocation  of  the  lens,  the 
immediate  pathological  factor  being  an 
atrophy  of  the  fibres  of  the  suspensory 
ligament:  a  condition  described  by  Wedl 
and  Bock  as  "senescence  of  the  zonula." 

Symptoms ;  Appearances ;  Vision.  — 
Any  change  in  the  position  of  the  lens 
destroys  the  normal  relations  between 
it  and  the  iris,  the  latter  losing  its  sup- 
port partially  or  totally,  according  to  the 
degree  of  the  displacement,  or  being  un- 
duly pressed  forward  or  backward,  or  dis- 
tended, according  as  the  lens  is  tilted 
against  portions  of  the  posterior  surface 
of  the  iris,  dislocated  into  the  anterior 
chamber,  or  fixed  in  the  pupil  itself. 
When  the  dislocation  is  incomplete  the 
anterior  chamber  is  deeper  at  the  point 
vacated  by  the  lens,  and  the  iris  of  the 
same  region  is  tremulous  on  quick  move- 
ments of  the  eyes  or  head.  In  the  slight- 
est degrees  of  dislocation  a  slight  tremu- 
lousness  of  one  portion  of  the  iris  may 
constitute  the  only  physical  sign  of  the 
lesion,  but  is  an  absolute  indication  that 
the  iris  no  longer  rests  on  the  anterior 
capsule  of  the  lens.  The  history  of  in- 
jury and  the  condition  of  vision  will  be 
necessary  to  lead  to  a  correct  diagnosis. 

Increased  depth  of  one  portion  of  the 


OF.  SYMPTOMS. 

anterior  chamber  may  be  accompanied 
by  increased  shallowness  of  another,  from 
tilting  forward  of  some  portion  of  the 
lens  against  the  iris  and  ciliary  body:  a 
relation  which  may  result  in  setting  up 
a  condition  of  glaucomatous  tension  and 
form  a  very  important  factor  in  the  prog- 
ress of  the  case. 

By  employing  focal  illumination  the 
edge  of  the  lens  can  be  seen  in  the  pupil, 
which,  however,  usually  requires  to  be 
dilated  for  this  purpose.  The  lens  itself 
will  appear  as  a  delicate  gray  compared 
with  the  pure  black  of  the  aphakic  por- 
•  tion  of  the  pupil,  and  its  edge  will  ap- 
pear luminous  on  account  of  the  total 
reflection  which  the  rays  of  light  enter- 
ing the  marginal  portions  of  the  lens 
from  the  front  undergo  at  its  posterior 
surface;  for  at  the  edge  of  the  lens 
they  strike  this  posterior  surface  very 
obliquely. 

With  the  ophthalmoscope,  on  the  other 
hand,  the  edge  of  the  lens  appears  black, 
for  the  same  reason,  the  light  coming 
into  this  portion  of  the  lens  from  the 
fundus  being  reflected  back  into  the  eye. 

When  there  is  complete  dislocation  of 
the  lens  there  will  be  an  absence  of  the 
catoptric  lenticular  images.  The  lens 
itself  when  opaque  may  be  visible 
through  the  pupil  with  the  naked  eye. 
As  a  rule,  however,  examination  with 
the  ophthalmoscope  is  necessary  for  its 
detection.  It  may  be  connected  with 
the  fundus  or  freely  movable  in  the  fluid 
vitreous  (cataracta  natans). 

There  is  now  more  marked  and  general 
tremulousness  of  the  whole  area  of  the 
iris  on  quick  movements  of  the  eyes  and 
head,  with  an  abnormally,  but  uniformly, 
deep  anterior  chamber. 

When  once  seen  there  is  no  difficulty 
in  determining  the  nature  of  the  floating 
body,  on  account  of  its  shape  and  size 
and  the  fact  that  no  other  condition 


LENS,  DISEASES  OF.    CONDITION  OF  VISION. 


341 


occurs  with  which  it  is  possible  to  con- 
found it. 

When  the  lens  is  displaced  into  the  an- 
terior chamber  its  appearance  is  charac- 
teristic, its  margin  having  a  golden  luster 
due  to  total  reflection  of  light,  making  it 
look  like  a  large  drop  of  oil  in  the  an- 
terior chamber,  which  is  much  deepened, 
especially  at  its  lower  part.  The  lens 
assumes,  moreover,  a  more  spherical  form 
than  when  in  situ,  on  account  of  the  loss 
of  the  compressing  influence  of  the  fibres 
of  the  suspensory  ligament  and  choroid, 
etc.  The  irritation  it  sets  up  often  causes 
a  contraction  of  the  pupil  behind  it. 

In  case  of  old,  traumatic,  dislocated, 
cataractous  lens  the  central  half  of  the 
pupillary  quarter  of  the  iris  was  altered 
in  color  and  in  brilliancy,  while  the  oph- 
thalmoscope revealed  an  alternate  free 
transmission  of  the  choroidal  reflex  and 
intercepting  radial  lines  of  iris-stroma-. 
This  latter  points  to  a  previously-existing 
radial  muscular  mechanism  in  the  once 
healthy  iris.  Symon  (Australasian  Med. 
Gaz.,  July  15,  '92). 

Condition  of  Vision. — Sight  is  always 
impaired  to  a  greater  or  less  extent.  In 
partial  dislocation,  vision  is  affected,  be- 
cause rupture  of  the  fibres  of  the  sus- 
pensory ligament  destroys  the  power  of 
accommodation,  and,  at  the  same  time, 
by  permitting  increase  in  the  convexity 
of  the  lens,  makes  the  eye  highly  myopic. 
Moreover, .  the  tilting  of  the  lens  on  its 
axis  induces  a  variable  amount  of  astig- 
matism, regular  and  irregular,  lateral 
displacement  having  a  similar  effect. 

In  higher  degrees  of  displacement, 
where  the  edge  of  the  lens  lies  across  the 
area  of  the  pupil,  not  only  is  there  a 
higher  degree  of  visual  failure,  but  there 
is  also  diplopia,  two  blurred  images  being 
seen.  This  is  due  to  the  fact  that  the 
edge  of  the  lens  acts  as  a  prism,  and 
causes  the.  rays  of  light  entering  the  eye 
through  it  to  be  deviated  in  the  direction 


of  the  dislocation,  while  those  entering 
the  aphakic  portion  of  the  pupil  are  un- 
changed in  direction  except  in  so  far  as 
they  are  made  to  converge  and  form  an 
indistinct  image  on  the  retina. 

•  Case  of  double  dislocation,  one  upward, 
the  other  downward,  with  atrophy  of  the 
zonula.  There  was  so-called  monocular 
triplopia  from  a  double  image  formed  by 
the  displaced  lens,  joined  to  a  third 
image  made  by  the  media  without  the 
lens.  Heddaeus  (Zehender's  klin.  Monats. 
f.  Augenh.,  May,  '88). 

Considered,  therefore,  with  regard  to 
that  portion  of  the  pupil  still  occupied 
by  the  lens,  the  eye  is  myopic,  and  the 
image  formed  by  the  light-rays  passing 
through  it  can  be  cleared  to  a  greater  or 
less  extent  by  concave  sphero-cylindrical 
lenses.  With  regard  to  that  part  from 
which  the  lens  is  absent,  the  eye  is  highly 
hypermetropic,  and  its  image  can  be 
made  clear  by  the  aid  of  a  convex  spher- 
ical glass,  and  such  a  cylinder  as  is  neces- 
sary to  correct  the  corneal  astigmatism. 
In  a  later  stage  vision  may  be  further 
impaired  by  the  development  of  opacities 
in  the  lens. 

When  the  lens  is  completely  dislocated 
into  the  vitreous  chamber,  and  no  com- 
plications have  arisen,  vision  resembles 
that  of  an  eye  after  cataract  extraction, 
and  the  condition  is  exactly  similar  to 
that  brought  about  by  the  operation  of 
reclination,  or  couching. 

The  patient  regains  good  vision  with 
the  aid  of  strong  convex  lenses,  which 
have  to  be  adjusted  for  distance,  and  also 
for  the  near  point  at  which  it  is  desired 
to  read  or  work. 

But  in  many  of  these  cases  complica- 
tions arise  which  prevent  perfect  vision 
from  being  attained,  or  in  course  of  time 
bring  about  its  impairment  in  varying 
degree.  Thus,  iridocyclitis  may  arise  and 
destroy  vision  and  even  set  up  sympa- 
thetic disease  in  the  fellow-eye.   Or  glau- 


342 


LENS,  DISEASES  OF.    PROGRESS  AND  RESULTS. 


comatous  tension  may  occur,  with  the 
same  result,  so  far  as  sight  is  concerned. 

Four  cases  of  spontaneous  luxation  of 
the  lens,  two  of  which  were  congenital. 
In  one  the  luxation  was  bilateral.  In 
three  instances  the  lens  had  to  be  ex- 
tracted, after  years  of  quiet,  upon  ac- 
count of  violent  glaucomatous  attacks. 
Armaignac  (Jour,  de  Med.  de  Bordeaux, 
June  23,  '95). 

Case  of  secondary  glaucoma  following 
partial  dislocation  of  lens;  removal  of 
lens;  cessation  of  all  pressure-symptoms 
Oliver  (Wills  Eye-Hosp.  Reports,  vol.  i, 
p.  1,  '95). 

Literature  of  '96-'97-'98. 

Case  in  which  a  lens  dislocated  into  the 
vitreous  during  a  cataract- operation  set 
up  so  much  sympathetic  disturbance  six 
months  later  that  enucleation  was  neces- 
sary. K.  Hoor  (Wien.  med.  Woch.,  Aug. 
22,  '96). 

Progress  and  Results.  —  Congenital 
dislocations  are  always  incomplete,  and 
the  lens  shows  no  special  tendency  to 
become  opaque:  good  evidence  that  its 
nutrition  is  unimpaired.  In  some  cases, 
however,  the  displacement  increases,  and 
complete  dislocation  into  the  vitreous 
or  anterior  chamber,  or  alternately  into 
each,  finally  occurs.  The  latter  condi- 
tion is  predisposed  to  by  abnormal  small- 
ness  of  the  lens:  a  common  characteristic 
in  cases  of  ectopia,  which  permits  its 
easy  passage  through  the  pupil.  When 
this  state  of  complete  luxation  has  been 
attained,  the  lens-substance  is  liable  to 
deteriorate  and  become  opaque.  Strik- 
ing against  portions  of  the  uveal  tract 
the  freely-movable  lens  may  set  up  irido- 
cyclitis, and  disorganization  of  the  eye 
and  destruction  of  vision  result.  Or,  as 
previously  stated,  secondary  glaucoma 
may  become  established  and  finally  lead 
to  blindness. 

In  two  cases,  father  and  daughter,  seen 


in  the  practice  of  the  writer,  the  father, 
aged  55,  had  opaque  lenses  freely  floating 
in  the  vitreous,  and  sometimes  passing 
through  the  pupil  into  the  anterior 
chamber,  with  occasional  glaucomatous 
attacks,  always  relieved  by  paracentesis. 
The  daughter  presented  typical  examples 
of  ectopia  lentis,  both  lenses  being  sta- 
tionary and  quite  clear.  Good  vision  was 
obtained  with  convex  lenses. 

Although  there  are  cases  in  which  a 
small  lens  may  pass  freely  through  the 
pupil,  as  a  rule,  a  lens  dislocated  into  the 
anterior  chamber  sets  up  violent  inflam- 
mation. The  irritation  caused  by  its 
pressure  on  the  anterior  surface  of  the 
iris  excites  contraction  of  the  pupil  and 
iritis,  which  fix  it  firmly  in  position.  Or 
a  few  white  spots  indicate  the  presence 
of  adhesions  between  the  lens  and  cornea, 
caused  by  inflammation  of  the  latter. 
There  is  glaucomatous  tension  and  rapid 
extinction  of  sight.  As  a  result  of  the 
increased  tension,  ectasia  of  the  anterior 
part  of  the  sclerotic  occurs,  and  a  general 
enlargement  of  the  eyeball. 

Spasm  of  the  sphincter  iridis,  just  re- 
ferred to,  may  occur  while  the  lens  is  in 
the  act  of  passing  through  the  pupil. 
There  then  arise  violent  inflammatory 
glaucomatous  symptoms. 

In  a  case  in  which  dislocation  of  - the 
lens  into  the  vitreous  occurred  as  one  of 
the  results  of  the  lodgment  of  a  small 
piece  of  steel  in  the  eye,  the  lens  was 
found,  after  enucleation  on  account  of 
persistent  pain  due  to  absolute  glaucoma, 
to  be  completely  opaque  and  black.  The 
source  of  the  pigment  was  quite  evident, 
for  the  choroid  was  apparently  entirely 
devoid  of  it.  The  foreign  body  was  en- 
cysted in  fibrous  tissue  attached  to  the 
retina  near  the  equator.  The  emulation 
was  performed  about  twenty-live  years 
after  the  injury,  the  eye  having  been 
blind  for  many  years. 


LENS,  DISEASES  OF.  TREATMENT. 


343 


Treatment. — When  no  symptoms  other 
than  impairment  of  vision  exist,  suitable 
glasses  may  be  prescribed;  but  when  one 
eye  only  is  the  subject  of  dislocation,  the 
other  being  normal  and  of  good  visual 
acuity,  the  patient  will  get  on  better 
without  a  correcting  glass,  depending  on 
the  good  eye  for  clear  vision.  In  cases 
of  subluxation,  the  margin  of  the  lens 
lying  in  the  pupil,  the  kind  of  lens 
ordered  depends  upon  whether  better 
vision  can  be  obtained  by  correcting  the 
portion  of  the  pupil  containing  the  lens, 
the  myopic  area,  or  the  aphakic,  hyper- 
metropic area.  This  can,  of  course,  only 
be  ascertained  by  actual  experimentation. 

Sometimes  better  vision  can  be  ob- 
tained by  enlarging  the  aphakic  portion 
of  the  pupil  by  a  small  iridectomy. 
Other  things  being  equal,  this  portion  is 
to  be  preferred  for  correction  on  account 
of  the  greater  size  of  the  retinal  images 
so  obtained. 

When  the  dislocation  is  complete,  the 
lens  being  in  the  vitreous,  the  case  is 
precisely  similar  from  a  refraction  stand- 
point to  one  of  aphakic  after  cataract 
extraction.  Under  all  conditions  two 
pairs  of  glasses  are  required:  one  for  dis- 
tance and  another  for  reading  or  working 
distance. 

But  in  many  cases  other  symptoms  be- 
sides disturbances  of  vision  are  present 
at  an  earlier  or  later  stage  in  the  case. 
In  cases  of  partial  dislocation  pressure 
of  the  lens  against  the  ciliary  margins 
of  the  iris  and  the  ciliary  body  may  set 
11 1 )  i^mcomatous  symptoms.  In  this  case, 
if  removal  of  the  lens  be  not  deemed 
feasible,  an  iridectomy  may  be  made  at 
the  point  where  the  lens  is  in  contact 
with  the  iris. 

Removal  of  the  partially-dislocated 
lens  is  always  difficult,  and  apt  to  be  com- 
plicated with  loss  of  vitreous,  on  account 
of  the  condition  of  the  suspensory  liga- 


ment, which  is  either  congenitally  defi- 
cient or  damaged  by  traumatism. 

Great  stress  laid  upon  the  importance 
of  the  immediate  use  of  a  mydriatic  in 
injury  of  the  lens.  Millikin  (Jour.  Amer. 
Med.  Assoc.,  Sept.  3,  '92). 

In  a  case  of  secondary  glaucoma  from 
partial  dislocation  of  the  lens  into  the 
anterior  chamber,  removal  of  the  lens  was 
followed  by  immediate  cessation  of  all 
pressure  symptoms.  In  this  case  the 
lower  half  of  a  densely-cataractous  lens 
had  pushed  its  way  through  the  pupillary 
opening  and  had  pressed  the  iris  in  this 
position  far  back  behind  it.  To  effect  its 
removal  a  peripheral  incision  was  made 
in  the  lower  outer  third  of  the  cornea. 
A  wire  loop  was  introduced  and  the  lens 
was  extracted  without  the  loss  of  any 
vitreous,  obtaining  a  clear  and  round 
pupil.  Oliver  (Wills  Eye-Hosp.  Reports, 
vol.  i,  p.  1,  '95). 

Literature  of  '96-'97-'98. 

Slight  partial  dislocation  of  the  lens 
can  be  cured  by  the  continued  use  of 
atropine,  which  gives  the  zonula  a  chance 
to  repair,  or  by  eserine  if  vision  is  im- 
proved by  its  instillation  and  where  the 
tests  show  that  atropine  produces  a  still 
further  tilting  of  the  lens.  Dunn  (Va. 
Med.  Semimonthly,  Jan.  2,  '97). 

When  the  lens  is  dislocated  into  the 
anterior  chamber,  extraction  is  compara- 
tively easy,  and,  moreover,  absolutely 
necessary.  If  it  is  not  done,  vision  is  in- 
evitably lost,  The  lens  is  fixed  in  the 
anterior  chamber  by  the  use  of  miotics  or 
the  introduction  of  Agnew's  bident,  and 
the  ordinary  corneal  incision  for  cata- 
ract made.  Delivery  has  to  be  accom- 
plished by  means  of  the  vectis,  wire  loop, 
or  sharp  hook. 

Six  cases  of  successful  extraction  of 
luxated  lenses  by  the  assistance  of  the 
Agnew  bident.  In  the  use  of  the  instru- 
ment, the  lens  should  not  be  pressed  too 
far  into  the  anterior  chamber,  as  in  per- 
forming the  after-section  for  the  extrac- 
tion of  the  lens;  the  iris  and  the  lens  are 
thus   rendered  more  liable   to  be  cut 


344 


LENS,  DISEASES  OR  TREATMENT. 


through,  or  the  section  itself  may  be 
forced  to  insufficient  size.  Pomeroy  (New 
England  Med.  Mthly.,  May,  '89). 

Three  completely  luxated  lenses  suc- 
cessfully removed  by  the  aid  of  an  elec- 
tric photophore,  which  was  made  to 
illuminate  the  interior  of  the  eye.  After 
the  illumination  had  been  effected  a 
pointed  hook  was  introduced  through  the 
sclera  to  fix  the  lens,  which  latter  was 
held  in  position  while  an  assistant  lacer- 
ated the  capsule  with  a  cystitome  that 
had  been  introduced  into  the  anterior 
chamber.  The  resulting  soft  cataracts 
were  removed,  six  or  eight  days  after,  by 
aspiration.  Abadie  (Recueil  d'Ophtal., 
Aug.,  '92). 

Traumatically  dislocated  lens  success- 
fully removed  from  anterior  chamber 
of  an  eye  presenting  glaucomatous  symp- 
toms. After  transfixing  the  lens  with  a 
stop-needle,  extraction  Avas  accomplished 
by  introducing  a  wire  loop  through  a 
broad  peripheral  corneal  incision;  .  owing 
to  an  irreducible  prolapse  of  the  iris,  an 
iridectomy  had  to  be  made.  Healing  was 
uninterrupted,  and  normal  vision  with  a 
correcting  glass  was  regained.  Oliver 
(Annals  of  Ophthal.  and  Otol.,  July,  '92). 

Case  of  luxation  of  the  lens  into  the 
vitreous  which  caused  no  symptoms  for 
three  years,  and  then  from  some  unknown 
cause,  the  lens  having  passed  into  the 
anterior  chamber,  the  eye  became  very 
painful.  Massage,  which,  being  done 
with  the  fingers  on  the  closed  lids,  forced 
the  cataractous  lens  back  into  the  vitre- 
ous. To  prevent  recurrence,  the  pupil  was 
kept  small  by  miotics.  Boggi  (Ann.  di 
Ottal.,  xxv,  i,  p.  77). 

When  the  lens  floating  in  the  vitreous 
causes  iridocyclitis  or  secondary  glau- 
coma, its  removal  is  indicated.  To  do 
this  is  a  matter  of  great  difficulty.  If 
the  case  be  one  in  which  the  lens  some- 
times passes  into  the  anterior  chamber, 
attempts  should  be  made  to  bring  about 
this  change  of  position  by  such  move- 
ments as  have  previously  effected  it. 
Once  in  the  anterior  chamber  it  should 
be  fixed  there  by  the  use  of  a  miotic  or 
by  the  introduction  of  Agnew's  bident 


behind  it.  If  the  lens  cannot  by  volun- 
tary movements  be  made  to  enter  the 
anterior  chamber,  it  may  be  brought  to 
the  anterior  part  of  the  eye  by  the  bident 
and  fixed  there.  It  may  then  be  removed 
by  corneal  incision,  and  its  delivery 
usually  requires  the  use  of  the  vectis,  or 
sharp  hook.  Some  vitreous  is  usually 
lost,  and  this  is  most  apt  to  occur  during 
the  removal  of  the  bident,  which  seems 
to  be  the  most  dangerous  part  of  the 
operation. 

Luxated  lens  successfully  removed  from 
the  posterior  chamber  of  an  eye  by  first 
performing  a  downward  iridectomy,  fol- 
lowed two  months  later  by  extraction 
with  the  aid  of  a  curette,  a  small  amount 
of  vitreous  being  lost.  In  eighteen  days 
vision  equaled  two-thirds  of  normal. 
Despagnet  (Recueil  d'Ophtal.,  June,  '89). 

In  the  extraction  of  dislocated  lenses  it 
is  possible  "in  many  cases,  perhaps  in  the 
majority,  to  extract  the  lens  by  external 
pressure,  and  to  confine  the  use  of  instru- 
ments to  assist  in  the  removal  of  the  lens 
after  it  has  presented  in  the  wound,  or,  at 
least,  in  the  field  of  the  pupil."  C.  S. 
Bull  (N.  Y.  Med.  Jour.,  Sept.  6,  '90). 

Two  cases  of  dislocation  of  the  lens  into 
the  vitreous  humor,  in  which  extraction 
was  successfully  accomplished  by  first 
making  an  upper  corneal  section  and  then 
expelling  the  lens  by  methodical  external 
pressure  in  the  ordinary  manner,  the 
speculum  having  been  removed  during 
the  latter  part  of  the  procedure.  Knapp 
(Archives  of  Ophthal.,  Jan.,  '90). 

Literature  of  '96-'97-'98. 

Lens  dislocated  into  the  vitreous  re- 
moved without  iridectomy  while  the  pa- 
tient was  lying  prone  on  an  operating- 
table.    Higgins  (Lancet,  Dec.  26,  '96). 

Knapp  and  Bull  maintain  that  such 
lenses  can  be  removed,  and  have  pub- 
lished reports  of  cases  showing  such  to  be 
the  case,  without  the  use  of  the  bident, 
and  without  the  introduction  of  any  in- 
strument into  the  eye,  by  means  of  exter- 
nal manipulation  only. 


LENS,  DISEASES  OF.    CONGENITAL  ANOMALIES. 


345 


When  an  eye  is  blind  and  the  seat  of 
absolute  glaucoma  or  of  iridocyclitis  due 
to  dislocated  lens,  the  pain  so  caused  is 
best  relieved,  and  the  danger  of  sympa- 
thetic affection  of  the  other  eye  most 
effectually  avoided  by  enucleation. 

In  a  case  of  dislocation  of  both  lenses 
into  the  vitreous,  of  congenital  origin, 
reported  by  Bickerton  in  the  Trans.  Oph. 
Soc.  U.  Iv.,  '98,  the  lens  of  one  eye  passed 
into  the  anterior  chamber,  causing  re- 
duction of  vision  to  the  perception  of 
light  and  shade.  After  sixteen  days  the 
lens  was  replaced  in  the  vitreous  by  a 
spatula  introduced  through  a  corneal  in- 
cision, with  the  restoration  of  perfect 
vision,  the  aphakic  refraction  being  cor- 
rected. 

Case  of  spontaneous  dislocation  of  both 
crystalline  lenses  into  the  anterior  cham- 
bers occurring  in  myopic  eyes.  The  right 
eye,  which  was  entirely  blind  and  painful, 
was  enucleated,  while  from  the  left  an- 
terior chamber  a  partially- degenerate  lens 
was  successfully  removed.  With  the  ex- 
ception of  an  aggravated  spasmodic  en- 
tropion, necessitating  operative  inter- 
ference, rapid  healing  took  place,  leaving 
a  vision  of  10/10o,  without  the  necessity 
of  any  correcting  lens.  De  Schweinitz 
(Univ.  Med.  Mag.,  Nov.,  '89). 

Congenital  Anomalies. 

1.  Ectopia  lentis.  See  Anomalies  of 
Position. 

2.  Coloboma  lentis  is  a  rare  condition 
due  to  arrest  of  development  at  a  late 
period  of  embryonic  growth.  The  fre- 
quent association  of  coloboma  of  the  iris 
and  choroid  with  it  suggests  its  relation 
to  imperfect  closure  of  the  foetal  cleft. 
Its  immediate  cause  lies  in  defective  de- 
velopment of  the  zonula  of  Zinn.  This 
is  developed  from  adhesions,  which  form 
between  the  sides  of  the  lens  and  ciliary 
body  during  the  stage  of  embryonic  life 
when  they  are  in  contact.  As  the  eye  en- 
larges, that  portion  of  the  capsule  to 
which  adhesions  have  failed  to  occur 


would  not  be  held  taut  and  made  to 
expand  like  the  remainder,  and  a  cor- 
responding depression  in  the  lens  would 
result.  Absence  of  the  ciliary  body 
would,  of  course,  be  a  probable  cause  of 
this  failure  to  adhere. 

Two  cases  of  coloboma  of  lens  in  a 
brother  and  sister  8  and  11  years  old, 
.  respectively.  The  condition  is  best  ex- 
plained as  the  result  of  an  alteration,  in- 
flammation, or  absence  of  formation  of  a 
portion  of  the  zonula,  which  would  per- 
mit but  a  part  of  the  lens  to  come  in  im- 
mediate contact  with  the  sclera,  and  that 
the  adhesion  thus  produced  would  be  the 
starting-point  and  cause  of  the  displace- 
ment of  the  lens.  Sous  (Jour,  de  Med.  de 
Bordeaux,  Oct.  13,  '95). 

Literature  of  '96-'97-'98. 

Instance  of  congenital  coloboma  of  the 
lens  in  the  left  eye  of  a  man  20  years  of 
age.  The  lens  could  be  seen  to  exist  only 
for  about  the  upper  half  of  the  pupillary 
space.  Extending  from  the  inferior  bor- 
der of  the  lens-substance  to  and  behind 
the  inferior  border  of  the  pupillary  mar- 
gin there  was  a  delicate  membrane  show- 
ing fine,  vertical  parallel  striae.  The  in- 
ferior border  of  the  lens  appeared  terraced 
and  transparent,  but  above  this  it  be- 
came opaque.  The  diameter  of  the  cor- 
nea was  from  one  to  two  millimetres  less 
than  that  of  the  right  eye.  The  iris  was 
dull  dirt  yellow,  that  of  the  fellow-eye 
being  brown.  In  two  places  the  pupillary 
membrane  could  be  seen.  Dunn  (Ar- 
chives of  Ophthal.,  July,  '96). 

Heyl  has  suggested  that  a  defect  in  the 
inferior  branches  of  the  hyaloid  artery, 
which  gives  nutrition  to  the  lens  while 
the  peripheral  fibres  are  developing, 
would  produce  just  such  a  defect. 

It  is  often  associated  with  coloboma  of 
the  iris  and  choroid,  and  with  disloca- 
tion and  small  size  of  the  lens.  There  is 
sometimes  more  or  less  opacity  of  the 
lens. 

Literature  of  '96-'97-'98. 

Two  cases  of  coloboma  of  the  lens.  In 
one  it  was  the  sole  anomaly  present;  in 


346 


LENS,  DISEASES  OF. 


APHAKIA. 


LENTICONUS. 


the  other  it  was  associated  with  partial 
coloboma  of  the  iris  and  choroid.  Rog- 
man  (Archives  d'Ophtal.,  May,  '96). 

Tremulousness  of  the  iris  has  been  ob- 
served, but  more  especially  in  cases  in 
which  ectopia  also  has  been  present. 

The  defect  usually  occurs  in  the  in- 
ferior quadrant,  but  has  been  seen  up- 
ward, outward,  and  down  and  out. 

Literature  of  '96-'97-'98. 

Case  of  coloboma  of  lens  in  a  young 
man,  whose  father  and  one  brother  pre- 
sented the  same  condition.  0.  B.V—1/20, 
0.  S.  Y=1/.,5}  increased  in  0.  D.  by  the 
almost  complete  closure  of  the  eyes  when 
the  patient  looked  at  near  objects.  The 
lenses  were  displaced  upward  and  inward, 
and  were  transparent,  presenting  neither 
coloboma  ( ?)  nor  atrophy.  The  ophthal- 
moscope showed  the  lens  a  refraction  of 
+  20  D.  and  through  the  aphakic  media 
of  —  8  D.  The  papilla  presented  a  physi- 
ological excavation  and  posterior  staphy- 
loma.   Hassler  (Lyon  Med.,  Feb.  9,  '96,). 

It  resembles  in  form  the  chord  of  an 
arc,  nearly  a  straight  line,  but  sometimes 
consists  of  a  complete  notch. 

It  may  occur  in  one  eye  or  in  both,  and 
is  most  commonly  associated  with  my- 
opia. Vision  is  almost  always  defective, 
ranging  from,  absolute  blindness  up  to 
V  =  y.4,  as  a  rule.  But  Bresgin  re- 
corded a  case  in  1874  with  V  =  2%o  an(i 
fair  accommodation. 

Accommodation  seems  to  be  usually 
present  in  those  cases  in  which  vision  is 
good  enough  to  permit  of  reliable  ob- 
servation of  this  point.  Nystagmus  is 
sometimes  present. 

A  case  has  been  observed  in  which  a 
projection  from  the  lens-margin  was  as- 
sociated with  a  coloboma  of  the  iris. 

3.  Congenital  Smallness  of  the  Lens. 
— In  these  cases  the  anterior  chamber  is 
deeper  than  normal,  and  the  iris  trem- 
ulous. The  condition  can  be  recognized 
only  after  dilatation  of  the  pupil  with  a 


mydriatic.  An  unusually  wide  space  is 
then  seen  between  the  pupillary  edge  of 
the  iris  and  the  margin  of  the  lens, 
which  stands  out  as  a  dark  ring  against 
the  fundus.  Unusual  smallness  of  the 
lens  often  accompanies  ectopia  and  colo- 
boma lentis. 

4.  Aphakia. — Cases  of  this  condition 
in  microphthalmia  eyes  have  been  re- 
ported, but  Lang  expresses  the  opinion 
that  in  many  the  absence  of  the  lens  is 
apparent  only,  it  being  really  only  dis- 
placed out  of  sight. 

5.  Lenticonus. — This  may  occur  at 
either  the  anterior  or  posterior  pole  of 
the  lens,  the  latter  being  by  far  the 
commoner  situation.  Only  two  instances 
of  the  former  are  on  record,  and  there 
is  doubt  whether  they  were  congenital 
or  acquired.  The  condition  resembles 
keratoconus.  Anterior  lenticonus  can 
easily  be  recognized  by  oblique  illumina- 
tion. 

Posterior  lenticonus  requires  the  oph- 
thalmoscopic mirror  for  its  diagnosis. 
It  gives  the  appearance  of  a  large  oil- 
drop  in  the  pupil,  with  a  dark,  well- 
defined  border.  Opacities  of  the  poste- 
rior pole  of  the  lens  are  often  associated 
with  it.  The  refraction  is  found  to  be 
different  through  the  central  and  periph- 
eral portions  of  the  lens.  In  one  case 
a  remnant  of  the  hyaloid  artery  was  ad- 
herent to  it. 

Reference  may  perhaps  be  made  here 
appropriately  to  the  somewhat  common 
cases  in  which  the  refraction  is  found, 
by  estimation  with  the  ophthalmoscope 
or  skiascope,  to  vary  in  different  parts 
without  any  other  indication  of  lenti- 
conus. Sometimes  decided  differences 
are  found  in  the  upper  and  lower  halves 
of  the  pupil.  Sometimes  the  division 
seems  sectional  in  character. 

Case  of  lenticonus  posterior  in  a  girl 
7  years  of  age.    Examination  of  the  eye 


LENS,  DISEASES  OF. 


LEPROSY. 


34T 


with  a  concave  mirror  revealed  a  bright, 
circular  patch,  apparently  about  4  milli- 
metres in  diameter,  located  between  the 
iris  and  the  fundus  in  the  antero-posterior 
axis  of  the  globe.  Upon  careful  study  of 
the  reflexes,  this  was  found  to  project  be- 
yond the  normal  curvature  of  the  lens 
about  0.05  millimetre.  The  refraction  of 
the  eye  through  the  centre  of  the  lens 
was  myopic  about  12  dioptres,  and 
through  the  periphery  there  was  an  hy- 
permetropia  of  3  V?  dioptres.  The  base 
of  the  cone  was  probably  2.5  millimetres 
in  diameter.  At  the  apex  there  was  a 
small  opacity,  possibly  the  remnants  of 
fcetal  blood-vessels.  The  eye  had  been 
convergent  since  infancy.  The  fellow-eye 
showed  remnants  of  the  foetal  pupillary 
membrane.  Weeks  (Archives  of  Oph- 
thal.,  Apr.,  '91). 

Case  of  lenticonus  in  a  man  65  years  of 
age.  When  the  cone  cannot  be  made 
visible  by  focal  illumination  the  points 
which  will  enable  a  diagnosis  to  be  made 
are:  1.  The  oil-globule-like  disk.  2.  The 
great  difference  in  refraction  between  the 
margin  of  the  lens  and  the  central  por- 
tion, the  latter  being  always  highly 
myopic.  3.  The.  kaleidoscopic  move- 
ments of  the  retinal  vessels.  4.  The  ex- 
elusion  of  conical  cornea.  Knaggs  (Lan- 
cet, Sept.  19,  '91). 

Cases  of  false  lenticonus;  diagnosis 
from  true  lenticonus  by  Purkinje's 
images.  Demicheri  (Annales  d'Ocul., 
Eeb.,  '95). 

Literature  of  '96-'97-'98. 

Lenticonus  posterior  in  a  9-year-old 
girl.  The  refraction  of  the  peripheral 
portions  of  the  lens  was  +  4  D.,  while  the 
central  portion  was  — 11 D.  Cramer 
(Klin.  Monatsb.  f.  prakt.  Augenh.,  Aug., 
'97). 

Two  rabbits'  eyes  with  lenticonus  pos- 
terior. Explanation  is  as  follows:  Lenti- 
conus arises  from  changes  in  the  posterior 
capsule,  the  hyaloid  artery  in  process  of 
absorption  stretching,  and  finally  rupt- 
uring, the  capsule.  Vitreous  liquid  then 
causes  the  lens-fibres  to  swell  and  pro- 
trude through  the  break  in  the  capsule. 
Baeck  (Archiv  f.  Augenh..  xxxvi.  2.  p. 
1G0,  '98). 


6.  Congenital  Cataract.  (See  Cata- 
ract.) 

7.  Remains  of  Hyaloid  Artery  and 
Branches. — Punctate  opacities,  usually 
situated  a  little  to  the  inner  side  of  the 

I  posterior  pole  of  the  lens,  whitish  by 
reflected,  dark  by  transmitted,  light,  not 
interfering  with  vision,  discovered  in- 
cidentally, have  been  attributed  by  Am- 
nion de  Beck  and  Mittendorf  to  incom- 
plete involution  of  the  hyaloid  artery. 

They  are  stationary  in  character,  vary 
in  size  from  a  mere  point  to  a  poppy- 
seed,  and,  although  usually  well  defined, 
fine  lines  have  been  observed  radiating 
from  the  edge  in  some  cases. 

In  some  cases  of  persistent  hyaloid 
artery  with  attachments  to  the  lens, 
straight  vessels  have  been  seen  coming 
from  the  end  of  the  disk-like  attach- 
ment to  the  lens,  and  disappearing  into 
the  ciliary  region  at  the  margin  of  the 
pupil. 

Parasites. — Three  have  been  described 
as  occurring  in  the  lens:  monostoma, 
distoma,  and  filaria,  the  latter  occurring 
in  opaque  lenses  and  discovered  after 
•removal  of  the  latter  on  account  of  the 
opacity. 

Edward  Jacksox, 

Denver. 

LEPROSY. 

Definition. — Leprosy  is  a  chronic  dis- 
ease closely  allied  to  tuberculosis,  ac- 
quired by  inoculation  with  Hansen's 
bacillus  lepra?,  but  only  while  the  sys- 
tem is  susceptible  to  infection  through 
vital  adynamia,  inherited  or  acquired. 

[This  definition  differing  etiological! y 
from  all  those  found  in  literature,  it  is 
merely  submitted.  It  seems  to  advan- 
tageously group  the  solid  data  recorded 
and  to  throw  light  upon  some  mooted 
points.    C.  E.  de  M.  Sajous.] 

Varieties. — It  is  customary  to  divide 
leprosy  into  two  —  sometimes  three  — 


348  LEPROSY.  ! 

general  forms,  the  tubercular,  and  the 
anaesthetic,  the  former  being  character- 
ized by  the  formation  of  tubercle-like 
nodules;  the  latter  by  anaesthetic  areas 
denoting  a  special  involvement  of  the 
nervous  supply. 

[The  two  main  forms  differ  only  in 
respect  to  the  tissues  involved  as  a  result 
of  infection.  In  many  cases  they  but 
represent  individual  stages  of  the  disease 
and  are  often  blended,  the  symptoms  of 
both  forms  being  present  simultaneously. 
In  text-books  the  peripheral  manifesta- 
tions are  alone  dwelt  upon  as  initial 
symptoms;  in  this  review,  the  early 
manifestations  of  the  typical  disease, 
those  of  the  upper  respiratory  tract,  will 
receive  due  attention.  C.  E.  de  M. 
Sajotjs.] 

Symptoms. — The  earliest  symptoms  of 
leprosy  in  the  majority  of  cases,  accord- 
ing to  Morrow  (who  claims  to  have  first 
called  attention  to  the  early  evidences 
in  the  nasal  mucous  membrane)  and 
other  observers,  are  alteration  of  the 
voice,  betrayed  by  a  slight  husky  or 
rough  phonation — Besnier's  voix  lepreuse 
— which  he  likewise  considers  an  early 
sign;  rhinitis,  with  an  abnormally  free 
nasal  secretion,  sometimes  epistaxis,  and 
an  increase  in  the  salivary  secretion. 

Leprosy  is  always  chronic.  At  its  onset 
nasal  or  cutaneous  involvement  is  first 
observed.  Of  the  internal  organs,  the 
the  lungs  and  the  spleen  are  first  affected; 
later,  the  liver  and  intestines;  the  kid- 
neys very  rarely.  Albuminuria  is  uncom- 
mon. The  nervous  system  is  frequently 
involved.  Goldschmidt  (La  Lepre;  Soc. 
d'Ed.  Scientif.,  Paris,  '94). 

Sticker  noted  that  the  nasal  mem- 
brane could  appear  normal  in  the  first 
stage  or  at  most  show  a  slight  increase 
of  secretion.  The  first  visible  change 
is  a  simple  dry  catarrh  in  circumscribed 
patches,  which  eventually  present  a  raw 
surface.  In  advanced  cases  shallow  or 
deep  ulcers  are  visible  in  one  or  both 
sides  of  the  septum.    Sometimes  there 


SYMPTOMS. 

is  only  a  hard  swelling,  which  may  be 
extended  to  adjacent  parts  and  produce 
stenosis. 

Literature  of  '96-'97-'98. 

Leprous  lesions  of  the  nasal  fossa,  the 
mouth,  throat,  and  larynx  found  in  60 
per  cent,  of  the  cases  examined.  Con- 
clusions that  chronic  coryza  is  often  the 
first  exterior  manifestation  of  leprosy, 
and  that  the  nasal  mucus  of  lepers  is  of 
great  virulence  and  constitutes  one  of  the 
most  efficient  sources  of  the  propagation 
of  leprosy.  Jeanselme  and  Laurens  (Bull. 
Med.,  July  25,  '97). 

The  systemic  invasion  of  leprosy  is 
usually  slow,  years  rather  than  months 
constituting  the  period  of  incubation. 
Occasionally,  however,  its  onset  is  sud- 
den and  the  disease  progresses  rapidly. 
The  prodromal  symptoms  are  mainly 
those  of  general  neurasthenia:  anorexia, 
chilliness,  slight  ephemeral  fever,  mental 
inaptitude,  etc.  These  manifestations 
occur  by  exacerbations,  and  their  re- 
currence is  attended  by  more  or  less 
marked  impairment  of  sensibility  and 
other  cutaneous  functions,  perspiration, 
etc.,  over  restricted  areas,  fugitive  spots 
suggesting  slight  erythema. 

After  the  foregoing  symptoms  have 
shown  themselves  with  varying  activity 
at  various  times,  receding  as  often  with 
more  or  less  rapidity  and  completeness, 
the  erythematous  spots  become  more  per- 
sistent, are  more  highly  colored  and  sen- 
sitive to  the  touch,  and  project  beyond 
the  surface  to  a  greater  degree.  They 
are  reddish-brown,  gray,  dark-yellow  or 
bronze,  and  of  varying  size  from  that  of 
a  clime  to  that  of  the  palm.  They  may 
appear  over  any  part  of  the  body,  the 
face,  the  trunk,  and  extensor  portions  of 
the  limbs.  After  a  time  these  spots  also 
disappear,  leaving  a  discolored  patch, 
which  in  dark-skinned  persons  such  as 
I  the  resident?  of  South  American  coun- 


LEPROSY.    SYMPTOMS.  349 


tries,  appears  white  as  compared  to  their 
surroundings. 

[In  some  cases  I  had  occasion  to  see  in 
Mexico  the  appearance  of  the  patients 
suggested  the  spots  on  leopard  skins. 
C.  E.  de  M.  Sajous.] 

Tubercular  Form.  —  It  is  in  this 
form  that  the  naso-pharyngeal  phe- 
nomena are  most  marked.  The  patient 
experiences  slight  difficulty  in  breathing 
through  the  nose  and  the  symptoms  per- 
taining to  the  air-tract  already  described 
become  quite  marked.  Then  comes  the 
period  during  which  the  cutaneous  lepro- 
mata  of  Leloir  are  formed.  Localized 
nodosities  appear  over  various  regions, — 
the  face  and  hands  particularly, — vary- 
ing in  size  from  small  shot  to  a  chestnut. 
The  skin  appears  much  thickened,  hard- 
ened, and  puckered,  wrinkles  being 
turned  into  deep  furrows;  the  hairs  are 
often  changed  in  color  and  fall  out. 
The  projecting  portions  of  the  head — 
the  nose,  chin,  and  ears — taking  part  in 
the  thickening,  the  face  acquires  a  char- 
acteristic expression  which  fully  accounts 
for  the  horror  inspired  by  these  wretched 
cases.  The  extremities,  especially  the 
hands  and  feet,  are  generally  affected  in 
the  same  way.  Their  skin  being  thick- 
ened and  furrowed,  they  stand  out  stiffly 
and  are  used  with  difficulty. 

The  thickened  areas,  or  "tubercles," 
do  not  all  follow  the  same  course.  Some 
recede,  leaving  a  depressed  or  less  pig- 
mented spot,  while  others  proceed  to 
ulceration.  These  ulcers  are  usually 
small,  vary  in  depth,  and  their  borders, 
as  in  the  case  of  syphilis,  are  sharp-cut 
and  have  indurated  edges.  They  heal 
and  reappear  several  times  in  succession. 
When  the  ulcerative  process  invades  the 
deeper  tissues,  they  destroy  them;  mus- 
cles, tendons,  and  even  bone  yield  to  its 
ravages;  hence  the  mutilating  effects  of 
fhe  disease.    The  mucous  membranes  of 


the  mouth,  tongue,  pharynx,  and  larynx 
take  part  in  the  destructive  process.  The 
nasal  bones  and  cartilages  are  markedly 
involved:  the  typical  "saddle  nose,"  in- 
dicating destruction  of  the  supporting 
frame-work.  A  sniffling  respiration  in- 
dicates more  or  less  complete  obstruction 
to  the  respiration,  by  neoformations  or 
depressed  soft  tissues. 

Laryngeal  examination  of  a  series  of 
cases  of  leprosy.  In  one  the  entire  larynx 
was  involved;  the  epiglottis  was  com- 
pressed laterally  and  curved  backward; 
the  vocal  cords  were  covered  with 
numerous  round  nodules;  the  mucous 
membrane  of  the  subglottic  space  was 
thickened  and  pigmented,  as  was  that  of 
the  aryteno-epiglottic  ligaments.  A  sec- 
ond case  showed  diffuse  generalized  pig- 
mentation and  a  small  number  of  nodules. 
In  a  third  case  the  larynx  was  filled  with 
nodules,  occupying  especially  the  free 
part  of  the  epiglottis;  the  superior  vocal 
cords  were  irregular  and  the  inferior  left 
cord  thickened.  In  a  fourth  the  laryngeal 
mucous  membrane  was  almost  entirely 
destroyed,  the  ventricle  and  vocal  cords 
were  covered  with  many  nodules,  and 
there  was  considerable  ulceration  of  the 
lower  part  of  the  cords.  In  a  fifth  case 
the  internal  surface  of  the  larynx  was 
completely  destroyed,  and  in  the  sixth 
there  was  diffuse  hypertrophy  of  the  en- 
tire mucous  membrane,  but  no  nodules. 
Bergengriin  (Univ.  Med.  Jour.,  Apr.,  '94). 

Tubercular  leprosy  progresses  slowly: 
eight  or  ten  years,  on  an  average.  It 
is  attended  by  eruptive  and  febrile  ex- 
acerbations, each  being  followed  by  a 
period  of  comparative  quiet.  Gradually, 
however,  the  patient  succumbs  through 
invasion  of  the  viscera,  and  death  usu- 
ally follows  some  intercurrent  disease: 
pneumonia,  pleurisy,  etc. 

Anesthetic  Leprosy. — In  this 
variety  the  spots  are  not  as  numerous, 
and  often  begin  in  the  palm  and  soles. 
They  resemble  those  in  the  tubercular 
form,  being  erythematous  and  hyper- 


350 


LEPROSY.  SYMPTOMS. 


chromic.  But  disorders  of  sensibility  are 
more  marked  from  the  start:  hyperes- 
thesia usually  precedes  ansesthesia,  and 
may  be  discerned  not  only  over  the  ery- 
thematous areas,  but  also  over  apparently 
healthy  regions. 

According  to  Dehio,  leprous  skin-spots 
do  not  correspond  to  the  distribution  of 


Schematic  drawing  representing  a  mixed 
nerve.  (Dehio.) 

the  nerves,  but  may  spread  in  all  direc- 
tions. Baelz  observed  that  when  the 
body  of  a  leper  was  rubbed  with  a  pow- 
der of  fuchsin  methyl- violet,  then  cov- 
ered closely  with  absorbent  cotton,  and 
pilocarpine  was  injected  into  the  patient, 
the  healthy  perspiring  skin  became  col- 
ored, whereas  the  leprous  non-perspiring 
spots  did  not. 


Leprous  skin-spots  do  not  correspond 
to  the  distribution  of  the  nerves,  but  may 
spread  in  all  directions.  Schematic  draw- 
ing represents  a  mixed  nerve.  A  and  G 
are  portions  of  skin  with  their  sensory 
nerve-twigs  (E  and  G)  ;  B  and  D  are 
muscles  with  their  motor  nerve-twigs 
{F  and  H)  •  I  and  K  are  mixed  nerve- 
fibres,  while  L  represents  the  nerve-trunk. 
The  shaded  portions  represent  the  locali- 
ties of  leprous  infiltration.  The  patches 
of  skin,  (A)  being  infected  with  leprosy 
and  becoming  anaesthetic  without  in- 
volvement of  the  nerve  (E) ,  subsequently 
an  ascending  degeneration  attacks  the 
nerve-fibres  of  E  and  proceeds  toward  /. 
After  a  long  time  the  leprous  infiltration 
also  reaches  E,  but  does  not  produce  any 
clinical  change.  So  soon,  however,  as  the 
mixed  nerve  (/)  is  reached,  all  peripheral 
to  that  becomes  atrophied,  and  we  have 
degenerative  atrophy  of  the  muscle,  al- 
though neither  it  nor  the  motor  nerve 
reaching  it  has  been  attacked  by  leprous 
infiltration.  When,  finally,  the  leprous 
infiltration  creeps  up  and  localizes  itself 
at  L,  the  whole  nerve  below  this  point 
becomes  atrophied,  including  K,  G,  and 
H,  which,  nevertheless,  are  free  from  lep- 
rous infiltration.  The  result  is:  anaes- 
thesia of  the  patch  of  skin  (C),  which 
itself  is  not  affected  with  leprosy,  and 
degenerative  atrophy  of  the  muscle  (D). 
Dehio  (St.  Petersburger  med.  Woch.,  Xo. 
42,  p.  632  et  scq.,  '89). 

The  anaesthesia  is  so  marked  that  pin- 
pricks, burns,  etc.,  are  not  felt.  On  the 
other  hand,  prickling  and  violent  shoot- 
ing pains  are  often  complained  of,  cer- 
tain nerves,  particularly  the  ulnar  and 
brachial  being  sometimes  greatly  thick- 
ened and  extremely  sensitive  to  pressure. 
There  is  also  exaggeration  of  the  tendon- 
reflex.  Paralysis  of  several  muscles  may 
occur,  with  all  its  attending  complica- 
tions. Considerable  mutilation  occurs 
in  this  form:  the  toes  and  fingers  are 
destroyed,  the  loss  being  unattended  by 
physical  pain. 

The  general  health  gradually  suc- 
cumbs to  the  ravages  of  the  disease,  and, 
the  viscera   becoming   involved,  albn- 


LEPROSY. 

minima,  diarrhoea,  pneumonia,  or  some 
other  intercurrent  disorder  ends  the  pa- 
tient's suffering. 

Complications  of  Both  Forms.  — 
Ocular  affections  of  leprosy  were  studied 
by  Panas.  In  the  anaesthetic  form,  lag- 
ophthalmos,  xerosis  of  the  conjunctiva 
and  iritis,  cataract,  and  phthisis  bulbi 
are  frequent;  in  the  tuberculous  varie- 
ties the  cornea  and  conjunctiva  are  the 
chief  seats  of  the  lesion,  though  some- 
times the  iris,  lens,  and  whole  globe  be- 
come implicated.  The  favorite  seat  is  the 
corneo-scleral  border,  proceeding  thence 
into  the  corneal  substance  and  to  the 
deeper  tissues. 

The  iris  becomes  the  seat  of  colonies, 
and  the  parasite  reaches  the  ciliary  proc- 
esses, but  the  number  decreases  toward 
the  optic  nerve.  Lesions  show  that  it 
proceeds  from  the  surface  to  the  inner 
parts  of  the  globe.  In  the  beginning  the 
lesion  is  circumscribed,  and  does  not  seem 
to  be  a  symptom  of  general  infection. 
Poncet  (Le  Prog.  Med.,  p.  33,  '88). 

Mental  disorders  are  occasionally  ob- 
served, melancholia  especially.  Inflam- 
matory and  diathetic  disorders  of  the 
brain  and  spinal  cord  have  also  been 
noted.  Of  the  36  autopsies  of  maculo- 
anaesthetic  form  studied  by  Havelburg, 
there  were  2  cases  of  simple  meningitis, 
1  tubercular  meningitis,  1  of  nodular 
tuberculosis  of  the  cerebellum,  2  of  hy- 
drocephalus, 2  of  degeneration  of  the 
posterior  columns  of  the  spinal  cord,  1 
of  atrophy  of  the  spinal  cord,  and  1  of 
thickening  and  hyperaemia  of  the  lumbar 
portion  of  the  spinal  cord. 

Literature  of  '96-'97-'98. 

Leprosy  exerts  a  direct  influence  on  the 
development  of  dementia,  the  cerebral 
phenomena  resulting  possibly  from  some 
irritating  lesions  of  the  nervous  system, 
brought  on  either  by  Hansen's  bacilli  or 
by  their  toxins.  Meschedes  (Section  of 
Neurol.,  Inter.  Med.  Congress,  Aug.  19-26, 
'97). 


DIAGNOSIS.  351 

Ten  autopsies  of  lepers  who  had  died 
in  the  leprosy  of  Riga,  and  in  four  of 
these  cases  there  were  adhesions  between 
the  dura  mater  and  the  brain;  in  three 
of  these  four  cases  of  adherent  meningitis 
lepra  bacilli  were  found  on  a  level  with 
the  pituitary  gland.  C.  Brutzer  (St. 
Petersburger  med.  Woch.,  Oct.  17,  19, 
No.  42,  p.  363,  '98). 

Lepers,  male  and  female,  suffer  from 
marked  deterioration  of  the  genital  func- 
tions, and  male  lepers  generally  become 
impotent. 

Of  118  cases  of  leprosy  in  the  Punjab, 
73  cases  married  before  the  onset  of  the 
disease,  viz.,  43  males  and  30  females;  and, 
while  still  healthy,  the  males  had  71  chil- 
dren, mostly  now  living  free  from  the  dis- 
ease, and  the  females  had  65;  total,  136. 
After  the  disease  had  declared  itself  only 
4  females  gave  birth  to  offspring, — 5  in 
all.  Sixteen  males  and  23  females  mar- 
ried after  leprosy  had  declared  itself.. 
Seven  married  more  than  once;  thus,, 
one  man  married  five  wives  in  suc- 
cession, and  several  others  married  two- 
or  three  times.  The  men  contracted  26 
marriages,  the  women  29.  Only  5  men 
proved  prolific,  with  10  children,  and  8' 
women  with  15  children.  Four  children 
are  dead;  so  that  we  have  left  21  as  the 
progeny  of  55  marriages.  Guiana  Mustafa 
(St.  Louis  Med.  and  Surg.  Jour.,  May, 
'91). 

Diagnosis. — The  diseases  from  which 
leprosy  requires  differentiation  are  sy- 
ringomyelia, ainhum,  tuberculosis,  and 
syphilis.  The  similarity  between  leprosy 
and  the  two  diseases  first  mentioned  is 
such  that  they  have  been  considered 
identical  by  some  competent  observers. 

Syringomyelia. — In  this  disease 
Hansen's  bacillus  is  absent.  The  fre- 
quent rise  of  temperature  characterizing 
leprosy  does  not  attend  syringomyelia. 
Though  both  diseases  progress  slowly, 
the  active  symptoms — headache,  pares- 
thesia, neuralgic  pains — appear  earlier 
in  the  former,  while  the  dermal,  mus- 
cular, vasomotor,  and  skeletal  morbid 


352 


LEPROSY.  DIAGNOSIS. 


changes  do  not  appear  in  the  regular 
order  as  they  do  in  syringomyelia.  The 
hands  and  feet  are  first  involved  in  lep- 
rosy;   in   syringomyelia  the  proximal 
parts  of  the  limbs  are  first  attacked  and 
the  destructive  process  is  less  marked. 
Syringomyelia  and  leprosy  are  sub- 
stantially different  affections,  both  in  re- 
gard to  their  etiology  and  nature,  not- 
withstanding the  fact  that  some  cases 


syringomyelitic  type."  in  which  only  bac- 
teriological examination  determined  the 
true  affection.  In  the  portion  of  nerve 
excised  from  the  living  patient  the  bacil- 
lus of  leprosy  was  found  in  great  num- 
bers, limited,  however,  to  the  nerve- 
fasciculus  itself,  none  being  found  in  the 
perineum,  the  intrafascicular  tissue,  nor 
in  the  vessels.  Pitres  and  Sabrazes 
(Nouvelle  Icon,  de  la  Salpetriere,  No.  3, 
'93). 


Fig.  1. — Posterior  aspect  of  a  case  of  leprosy  of  the  mixed  type, 
i  Hersman  and  Lyon.) 


present  a  certain  analogy  in  the  symp- 
toms. The  differential  diagnosis  between 
these  two  diseases  is  sometimes  very 
difficult.  Pitres  and  Sabrazes  (Archives 
Clin,  de  Bordeaux,  May.  '93). 

"While  not  all  cases  of  syringomyelia 
are  to  be  pronounced  as  leprosy,  at  least 
all  those  of  Morvan's  type  should  be. 
Prus  (Pharm.  Post.  Nos.  48  to  52.  '93). 

Case  of  "systematic  nervous  leprosy. 


Leprosy  often  first  manifests  itself  as  a 
non-characteristic  macule.  The  demon- 
stration of  lepra  bacilli  in  these  spots  is 
of  the.  highest  importance.  The  lesion 
should  be  excised,  taking  tissue  beyond 
the  anaesthetic  zone,  and  search  for  the 
bacilli  must  be  made  in  the  entire  thick- 
ness of  the  derma.  Marcano  and  YVurtz 
(Arch,  de  MM.  Exper.  et  d'Anst.  Path., 
Jan.,  '95;  Univ.  Med.  Mag.,  Apr.,  '95). 


LEPROSY.    DIAGNOSIS.  353 


According  to  Evaristo  Garcia,  the 
process  of  resorption  of  phalanges  in  the 
nervous  leprosy  of  tropical  South  Amer- 
ica is  perfectly  comparable  to  the  process 
of  destruction  of  the  bones  in  the  tabetic. 
Ashmead  (Jour.  Amer.  Med.  Assoc.,  Mar. 
16,  '95). 

Literature  of  '96-'97-'98. 

Case  of  mixed  leprosy,  illustrating  both 
the  distribution  of  the  anaesthetic  areas 
and  the  muscular  degeneration  and  con- 
traction following  leprous  neuritis.  The 
lesions  produced  by  syringomyelia  have 
frequently  a  strong  superficial  resem- 
blance to  indistinct  cases  of  leprosy,  but 
the  absence  or  presence  of  the  distinctive 
bacillus  is  enough  to  distinguish  the  dis- 
eases. C.  F.  Hersman  and  H.  N.  Lyon 
(Inter.  Med.  Mag.,  July,  '96). 

The  pathology  as  well  as  the  sympto- 
matology of  leprosy  and  syringomyelia 
afford  sufficient  means  for  differential 
diagnosis. 

Symptoms  characteristic  of  leprosy — 
circumscript  areas  of  anaesthesia,  atrophy 
of  muscles,  and  trophic  and  vasomotor 
changes  in  the  skin,  bones,  and  joints — 
appear  in  no  regular  order.  In  syringo- 
myelia the  sequence  of  symptoms  depends 
upon  the  seat  of  the  disease  in  the  spinal 
cord;  when,  as  in  most  cases,  the  cervical 
or  dorsal  segment  is  affected,  then  the 
upper  extremities  will  be  first  attacked; 
the  lower  may  escape  for  years,  and  con- 
versely. The  face  escapes  nearly  always, 
or  suffers  only  in  the  latter  stages. 

Leprosy  attacks  chiefly  the  small  mus- 
cles of  the  hands  and  feet,  more  seldom 
those  of  the  forearm  or  leg;  syringo- 
myelia begins  in  the  proximal  parts  of 
the  extremities;  a  scapulo-humeral  type 
is  pretty  frequent. 

In  leprosy  the  sensations  of  pain  and 
temperature  and  of  touch  are  either  im- 
paired or  entirely  absent;  in  syringo- 
myelia the  sensation  of  touch  remains 
intact. 

A  slowly-progressing  curvature  of  the 
spine  and  disturbance  of  the  function  of 
bladder  and  rectum  further  characterize 
syringomyelia;  spindle-shaped  thicken- 
ing of  the  branches  of  the  peripheral 
nerves,  especially  the  peroneal  and  ulnar 
nerves,  distinguish  the  early  stage  of 


leprosy.  M.  Laehr  (Berliner  klin.  Woch., 
Jan.  18,  '97 ). 

Ainhum. — Though  Zambaco  considers 
that  etiologically  ainhum  and  leprosy 
may  be  identical,  their  clinical  aspects 
are  sufficiently  dissimilar  to  prevent 
errors  in  diagnosis.  Ainhum  occurs  ex- 
clusively in  negroes,  and  consists  in  the 
amputation  of  the  little  toe  by  an  ad- 
ventitious fibrous  band.  Hansen's  bacil- 
lus has  never  yet  been  found  in  the  dis- 
eased tissues. 

Tuberculosis. — From  this  disease 
leprosy  is  differentiated  mainly  by  the 
bacillus  and  through  the  absence  in 
tuberculosis  of  anaesthetic  areas.  The 
injection  of  tuberculin  may,  according 
to  Babes  and  Kalindero,  assist  in  the 


Fig.  2. — The  so-called  "leper-claw." 
(Hersman  and  Lyon.) 

differentiation.  In  tuberculosis  the  gen- 
eral reaction,  after  the  injection  of  tuber- 
culin, begins  about  six  hours  after  in- 
oculation; in  leprosy  it  generally  comes 
on  twenty-four,  or,  less  frequently,  in 
twelve  hours  after  inoculation. 

Literature  of  '96-'97-'98. 

Three  cases  of  lepra  with  ulcers  in  the 
intestines.  In  two  of  these  there  was  at 
the  same  time  tuberculous  disease  of  the 
lung.  The  ulcers,  however,  were  dis- 
tinguished by  great  thickening  and  bluish 
coloration  of  the  edges.  In  the  third  case 
the  ulcer  was  flat,  rounded,  and  with  a 
sharp  edge.  No  tuberculosis  of  other 
organs  could  be  discovered.  Microscop- 
ically lepra  bacilli  were  found  in  the 
third  case,  while  in  the  ulcers  of  the  first 
and  second  bacilli  could  onlv  be  found. 


4—23 


354  LEPROSY.    DIAGNOSIS.  ETIOLOGY. 


Von  Reisner  (Monats.  f.  Prakt.  Derm., 
No.  5,  '96). 

Syphilis. — The  course  of  this  disease 
usually  serves  to  facilitate  diagnosis, 
while  Hansen's  bacillus  is  not  to  be 
found.  Fournier  states  that  general  or 
local  analgesia  and  anaesthesia  are  fre- 
quently observed  in  syphilis;  he  found, 
however,  that,  if  present  at  all,  they  oc- 
cur on  the  dorsal  surface  of  the  meta- 
carpal portion  of  the  hand. 

A  case  of  tubercular  syphilis  bearing 
so  close  a  resemblance  to  tubercular  lep- 
rosy that  the  patient,  while  undergoing 
antisyphilitic  treatment,  was  arrested 
and  confined  in  a  leper  hospital.  The 
woman  had  a  typical  "facies  syphilitica 
leontiasis,"  as  described  by  Goutard;  the 
trunk  was  free  from  lesions,  but  there 
were  numerous  typical  tubercular  syphi- 
lides  scattered  over  the  extremities,  espe- 
cially on  the  extensor  surfaces  of  the 
forearms.  Analgesia  and  anaesthesia 
were  present  over  all  the  spots,  and  also 
in  the  apparently  normal  surrounding 
skin,  especially  on  the  dorsal  surface  of 
both  metacarpi.  At  the  end  of  five  weeks 
of  specific  treatment  she  was  released 
from  the  leper  hospital  greatly  improved. 
McMurray  (Australasian  Med.  Gaz.,  Apr. 
15,  '93). 

Etiology. — That  leprosy  is  but  slightly 
contagious  is  the  opinion  of  the  great 
majority  of  dermatologists.  Not  only 
have  repeated  inoculations  failed  to  give 
rise  to  the  disease,  but  cases  have  been 
reported  showing  that  a  person  may  re- 
side with  a  leper,  sleep  and  eat  with  him, 
nurse  him,  handle  and  wash  his  linen, 
and  even  wear  his  clothes  with  impunity. 

In  spite  of  the  general  diffusion  of  the 
disease,  those  who  know  most  about  it 
doubt  its  contagiousness.  In  numerous 
mixed  marriages  coining  under  personal 
observation  the  disease  lias  never  been 
transmitted  from  one  parly  to  the  other. 
Often  a  single  member  of  a  family  is  a 
leper,  and  yet  mingles  without  restraint 
with  the  others,  adults  and  children. 
Nurses  and  attendants  in  leper  hospitals. 


often  religious  devotees,  care  for  lepers 
and  live  in  their  midst  for  years  without 
contracting  the  disease.  Zambaco  (Bull, 
de  l'Acad.  de  Med.  de  Paris,  No.  32,  '89). 

Literature  of  '96-'97-'98. 

Analysis  of  1034  cases  of  leprosy  in 
every  stage  of  the  disease.  Not  a  single 
case  could  be  traced  to  contagion  such  as 
sleeping  with,  eating  with,  or  nursing  a 
leper,  and  handling  or  wearing  his 
clothes.    Chew  (Med.  Age,  Dec.  27,  '98). 

Still,  there  is  considerable  testimony 
in  literature  tending  to  prove  that  lep- 
rosy is  contagious  under  certain  circum- 
stances, as  will  be  shown  under  Prophy- 
laxis. Observers  who  have  had  occasion 
to  study  large  numbers  of  cases  generally 
uphold  this  opinion. 

Clinical  evidence  tends  to  demonstrate 
that  leprosy  is  not  hereditary  in  the  true 
sense  of  the  word  (though  a  foetus  may 
be  infected  by  a  leprous  parent  and  be 
leprous  at  birth),  but  that  a  proclivity 
to  the  disease  is  inherited  by  the  off- 
spring, and  that  exposure,  in  his  case, 
will  lead  to  its  development. 

In  order  to  produce  the  contagion,  it  is 
necessary  that  the  person  contracting  the 
disease  be  under  the  influence  of  certain 
special  conditions,  and  surrounded  by 
certain  causes,  and  that  his  system  be 
prepared  beforehand  to  receive  the  lep- 
rous germ ;  in  other  words,  the  ground 
must  be  prepared  for  the  planting  of  the 
seed. 

"I  have  observed  many  cases  in  which 
the  disease  has  passed  from  generation  to 
generation,  and  have  noticed  that  lep- 
rosy, unlike  most  hereditary  complaints, 
rarely  disappears  in  one  generation  to 
reappear  in  the  next.  One  of  the  pa- 
tients being  a  leper,  the  son  is  in  immi- 
nent peril,  even  should  he  have  been  pro- 
created before  the  appearance  of  the  first 
symptoms  in  the  parent."  Florea  (Satel- 
lite of  tin4  Annual.  Nov..  'S7). 

Parasitism  does  not  necessarily  involve 
the  idea  of  contagion,  and  it  would  be  an 
error  to  believe  that  every  bacterial 
parasitic  disease  can  be  transmitted  from 


LEPROSY. 

the  affected  person  to  those  who  live  with 
him.  The  latter  must  be  in  an  especial 
condition  of  receptivity  in  order  that  con- 
tagion may  occur.  Cornil  (French  Acad, 
of  Med.,  Annual,  '89). 

In  the  Delta,  situated  two  kilometres 
from  the  French  Concession  of  Hanoi,  and 
containing  400  inhabitants,  almost  one- 
half  are  affected  with  leprosy.  Eighty 
to  90  per  cent,  of  the  children  of  lepers 
contract  the  disease,  which  usually  ap- 
pears for  the  first  time  about  the  eleventh 
year.  Editorial  (Brit.  Med.  Jour.,  Jan. 
3,  '91). 

Leprosy  is  a  family  disease,  and  chil- 
dren of  lepers  more  easily  acquire  leprosy 
by  early  infection.  Aiming  (Archiv  f. 
Derm.  u.  Syph.,  H.  1,  '91). 

Literature  of  '96-'97-'98. 

Leprosy  is  certainly  not  hereditary, 
and  can  only  be  spoken  of  as  possibly 
contagious,  an  absolute  demonstration  of 
infection  from  direct  contact  being  still 
lacking.  Possibility  suggested  that 
human  beings  are  but  temporary  hosts 
of  the  parasite,  it  having  possibly  some 
extrahuman  habitat.  K.  Grossman  (Brit. 
Med.  Jour.,  Dec.  5,  '96). 

Leprosy,  particularly  as  it  occurs  in 
Iceland,  has  increased  somewhat  in  recent 
years.  Of  119  cases  examined,  in  56  there 
was  a  history  of  the  disease  in  the  family. 
Of  these,  the  father  and  mother  were 
affected  in  3;  father  alone  in  15;  mother 
alone  in  4;  sisters  or  brothers  in  4;  dis- 
tant relatives  in  14.  Ehlers  (Derm.  Zeit,, 
No.  3,  '96). 

Investigation  of  1034  lepers.  Of  these 
10  were  born  leprous;  21  contracted  lep- 
rosy from  their  parents  before  puberty. 
The  disease  skipped  the  first  generation 
to  attack  the  second  in  some,  and  the 
third  in  others.  There  were  15  that  were 
born  leprous,  of  healthy  parents.  R.  8. 
Chew  (Med.  Age,  Dec.  27,  '98). 

Conditions  capable  of  sufficiently  re- 
ducing the  vital  resistance  of  the  or- 
ganism—  insufficient  or  unwholesome 
food,  excessive  use  of  salt,  a  fish  diet, 
exposure  to  cold  and  damp,  alcoholism, 
malaria,  overwork-,  syphilis,  tuberculosis, 
etc. — are  recognized  predisposing  factors. 


ETIOLOGY.  355 

They  seem,  in  my  opinion,  to  render  the 
organism  susceptible  to  the  influence  of 
the  leprosy  bacillus  precisely  as  does 
heredity. 

In  neither  of  its  true  forms  is  true 
leprosy  really  infectious,  and  if  it  be  con- 
tagious, which  is  personally  disbelieved, 
its  contagion  is  extremely  sluggish  and 
operative  only  under  telluric,  atmos- 
pheric, and  other  external  conditions  pre- 
disposing to  its  independent  development. 
George  Bird  wood  (Asiatic  Quarterly, 
Apr.,  '90). 

According  to  Jeanselme  and  Laurens, 
and  Sticker,  lepers  eliminate  the  bacillus 
of  leprosy  in  enormous  numbers  through 
the  upper  respiratory  tract  and  particu- 
larly the  nasal  cavities.  During  the 
active  stages  of  the  disease  the  nasal 
secretions  and  the  sputa  of  the  subjects 
thus  disseminate  the  bacillus  of  leprosy, 
by  emptying  their  nostrils  and  expecto- 
rating over  the  restricted  grounds  in 
which  they  are  segregated. 

Literature  of  '96-'97-'98. 

Leprosy  is  essentially  a  Chinese  dis- 
ease, extending  from  its  focus  in  the 
southeastern  provinces  to  every  region 
visited  by  the  lower  class  of  Chinamen, 
and  to  no  others.  James  Cantlie  (Lan- 
cet, Jan.  1,  '98). 

The  telluric  origin  of  leprosy  would 
thus  find  an  explanation.  Though  but 
slightly  communicable  by  the  leper  him- 
self when  free,  his  compulsory  segrega- 
tion within  a  certain  area  of  ground 
would  thus  cause  him  to  transform  this 
area  into  a  focus  of  infection.  His  spu- 
tum, nasal  secretion,  and  other  contam- 
inated ejecta  would  play  the  role  in 
leprosy  that  the  sputum  plays  in  the 
propagation  of  tuberculosis. 

[In  formulating  this  hypothesis  I  wish 
to  emphasize  the  fact,  that  it  is  only  sup- 
ported by  collateral  evidence.  Still  it 
seems  to  clear  many  mooted  points.  Tt 
was  therefore  deemed  sufficiently  sug- 


356  LEPROSY.  ETIOLOGY. 


gestive  to  merit  incorporation  in  these 
columns.   C.  E.  de  M.  Sajous.] 

Literature  of  '96-'97-'98. 

Personal  view  that  leprosy  is  of  telluric 
origin.  Long-continued  intimate  contact 
with  lepers  is  often  suffered  with  im- 
punity, while  leprosy  is  often  contracted . 
when  there  has  been  no  conscious  contact 
with  any  leper.  Evidently  the  discovery 
of  the  bacillus  leprae  does  not  necessarily 
imply  that  leprosy  is  spread  by  personal 
communication.  Tetanus  is  an  infective 
disease,  but  it  is  seldom  if  ever  main- 
tained by  communication  between  those 
suffering  from  it  and  the  healthy.  Ash- 
burton  Thompson  (Brit.  Med.  Jour.,  May 
7, '98). 

A  subject  predisposed  by  heredity  or 
debilitating  factors  could  thus  become 
infected  in  various  ways  by  dust  or  water 
contaminated  with  secretions  containing 
Hansen's  bacilli.  The  upper  respiratory 
tract  is  particularly  exposed  to  infection 
through  dust  inhaled.  The  breath  of 
the  patient,  especially  during  the  act  of 
•sneezing,  has  been  found  charged  with 
bacilli,  and  the  air  so  charged  may  come 
into  contact  with  the  nasal  mucous  mem- 
brane of  persons  in  the  immediate  vicin- 
ity. 

Literature  of  '96-'97-'98. 

The  front  part  of  the  nasal  mucous 
membrane  and  the  greater  portion  of  that 
covering  the  nasal  sputum,  is  the  region  I 
which  leprosy  first,  and  perhaps  always, 
attacks.  One  hundred  and  forty-three 
lepers  examined  to  ascertain  this  fact. 
In  55  out  of  57  cases  of  tubercular  lep- 
rosy the  leprous  bacillus  was  found  in 
the  nasal  secretion,  and  yet  in  only  2 
cases  were  there  any  leprous  nodules  in 
the  nose.  In  45  out  of  68  cases  of  anaes- 
thetic leprosy,  and  in  27  out  of  28  of  the 
mixed  form,  the  bacillus  was  also  found. 

In  23  out  of  153  cases  there  was  evi- 
dence of  disease  in  the  bronchi,  but  in 
only  14  of  these  were  leprous  bacilli  found 
in  the  sputum.  Tn  10  out  of  27  cases  in 
which  t ho  exudation  from  the  ulcers  was 
examined,  the  leprous  bacilli  was  found. 


In  21  cases  the  bacillus  was  demonstrated 
in  the  secretion  of  the  fauces  in  9  in- 
stances. Sticker  (Munch,  med.  Woch., 
Nos.  39  and  40,  '97). 

Experiments  showing  that  very  great 
numbers  of  bacilli  were  given  out  in 
sneezing, — in  one  instance  more  than 
110,000.  Conclusion  that  in  lepers  in 
whom  there  is  an  affection  of  the  mucous 
membranes  of  the  air-passages,  not  neces- 
sarily of  an  extreme  grade,  thousands  of 
bacilli  are  thrown  out  to  a  considerable 
distance  in  speaking,  coughing,  and 
sneezing,  and  that  this  dissemination 
cannot  be  prevented  by  therapeutic 
measures.  Dissemination  of  the  bacilli 
from  the  upper  air-passages  is  relatively 
the  most  important  of  the  various  ways 
of  infection.  Schaffer  (Archiv  f.  Derm, 
u.  Syph.,  '98;  Boston  Med.  and  Surg. 
Jour.,  Mar.  16,  '99). 

Abrasions  and  solutions  of  continuity 
of  the  skin  or  mucous  membrane,  etc., 
may  thus  also  afford  an  entrance  to  the 
specific  germ. 

Literature  of  '96-'97-'98. 

Twenty-six  cases  observed  in  which  in- 
oculation occurred  through  accidental 
abrasions  and  other  injuries.  Chew 
(Med.  Age,  Dec.  27,  '98). 

Morrow  advanced  the  theory  that,  like 
syphilis,  leprosy  was  usually  commu- 
nicated by  sexual  intercourse.  In  Chew's 
statistics  but  7  cases  out  of  1034  can  be 
traced  to  coitus;  but,  as  already  stated, 
the  period  of  incubation  of  the  leprosy 
is  long  and  the  disease  may  thus  fre- 
quently be  communicated  and  show  signs 
of  its  existence  long  after  intercouse. 
Hansen's  bacillus  has  been  found  in 
semen. 

Literature  of  '96-'97-'98. 

In  the  hospitals  in  Rio  Janiero  some  of 
the  attendants  have  been  attacked  in 
spite  of  thorough  precautionary  meas- 
ures. Period  of  inoculation  appears  to 
be,  in  some  cases  at  least,  as  much  as 
two  years,  and  may  possibly  be  longer. 
The  disease  is  frequently  associated  with 


LEPROSY.    ETIOLOGY.  DISTRIBUTION. 


357 


tuberculosis.  Havelburg  (Berliner  klin. 
Woch.,  Nov.  16,  '96). 

Women  in  China  are  active  dissemina- 
tors of  infection,  "selling  the  disease,"  as 
they  called  it,  in  the  belief  that  they 
can  free  themselves  by  coitus  with  a 
healthy  man.  James  Cantlie  (Lancet, 
Jan.  1,  '98). 

Of  the  1034  cases  studied  624  were  mar- 
ried, and  in  4  cases  only  did  the  husband 
infect  his  wife,  while  on  3  occasions  the 
wife  infected  her  husband.  While  44  of 
the  married  lepers  had  had  no  children, 
there  were  no  fewer  than  1566  concep- 
tions. R.  S.  Chew  (Med.  Age,  Dec.  27, 
'98). 

[Dr.  Chew's  statistics  seem  to  invali- 
date the  view  that  impotence  accounts 
for  limited  birth-rate  among  lepers.  As 
in  the  case  of  syphilis,  it  is  more  prob- 
able that  the  influence  borne  exerts  itself 
upon  fcetal  development.  C.  E.  de  M. 
Sajous.] 

Sex  does  not  seem  to  have  much  in- 
fluence upon  the  development  of  the  dis- 
ease, though  male  lepers  are  by  far  the 
more  numerous.  It  may  attack  children 
as  well  as  adults,  but  it  is  most  frequently 
met  with  in  persons  between  twenty  and 
forty-five  years  of  age:  the  period  of  life 
attended  by  the  greatest  exposure. 


Literature  of  '96-'97-'98. 

From  an  investigation  of  1034  lepers 
in  every  stage  of  the  disease  the  annexed 
table  gives  the  conclusions  reached  as  to 
etiology.  Roger  S.  Chew  (Medical  Age, 
Dec.  27,  '98). 

Distribution. — Leprosy  is  most  prev- 
alent in  India,  where,  according  to  Zam- 
baco,  there  are  130,000  cases;  but  the 
disease  is  thought  to  be  increasing.  It 
is  also  met  with  extensively  in  China; 
but  less  so  in  Persia,  Japan,  Tonquin,. 
Siam,  Anam,  the  Antilles,  and  South 
America. 

It  is  estimated  that  there  are  30,000 
lepers  in  the  departments  oi  Boyaca  and 
Santandeo,  in  the  "United  States  of 
Colombia.  E.  H.  Plumacher  (Abstract  of 
Sanitary  Reports,  Nov.  13,  '91). 

Leprosy  also  exists  in  Norway,  Sweden, 
Eussia,  Spain,  Italy,  Eoumania,  Greece, 
Turkey  (at  least  4000),  and  in  a  modified 
and  light  form  in  France. 

In  the  English-speaking  sections  of 
North  America  the  cases  are  compara- 
tively few.  An  inquiry  by  Dr.  Osier  has 
elicited  the  fact  that  there  were  five  foci, 
two  in  Canada,  aggregating  about  40 
cases,  and  three  in  the  United  States, 


Lepers  by  Nationality  and 
How  Disease  was  Obtained. 

Proved  to 
climatic  and 
telluric 
causes. 

Proved  to 
food  and 
drink. 

Proved  to 
direct  blood- 
taint— i.e., 
heredity, 
inoculation. 

Leprosy  to 
other  causes. 

Total  cases. 

M. 

F. 

M. 

F. 

M. 

F. 

M. 

F. 

M. 

F. 

Both 
Sexes- 

Adults. 

Europeans  and  East  Indians 
Mohammedans  

Total  

44 
68 
87 

252 

8 
22 
20 

1 
51 

9 
66 
50 
39 
164 

9 
22 
24 
26 
81 

48 
50 
37 
17 
152 

15 

3 
14 
(i 

38 

10 
44 
77 
13 
144 

10 

5 
18 

1 
34 

Ill 

228 
251 
102 
692 

42 
52 
76 
34 
204 

153 
280 
327 
136 
896 

Children. 

Europeans  and  East  Indians 

Mohammedans  

Hindoos  

Other  races  

Total  

4 
1 
11 

3 
19 

1 

2 
2 

5 

2 
1 

3 

6 

1 

o 
2 
5 

12 
13 
31 
7 
63 

4 
4 

12 
6 

26 

1 
1 

6 

2 

10 

3 
1 
4 

19 
16 
51 
12 

98 

5 

5 
19 

11 

40 

24 
21 
70 
23 
138 

Total  of  all  ages  

251 

56 

170 

86 

215 

64 

154 

38 

790 

244 

1034 

358 


LEPROSY.  PATHOGENESIS. 


aggregating  about  300  cases.  Dr.  I. 
Dyer,  at  the  Berlin  Leprosy  Conference, 
reported  that  there  were  126  cases  in 
Louisiana.  Wisconsin  and  Minnesota 
are  computed  to  contain  about  150,  all 
Swedes  and  Norwegians.  The  cases  are 
gradually  decreasing  in  number.  In  the 
Hawaiian  Islands,  according  to  Morrow, 
there  are  about  1200  cases  at  Molokai. 
Sporadic  cases  are  occasionally  met  with 
in  our  cities. 

Since  18G6  five  deaths  from  leprosy 
have  been  reported  in  New  York.  Edi- 
torial (Brit,  Med.  Jour.,  Dec.  19,  '91). 

Pathogenesis. — A  specific  bacillus 
closely  allied  to  the  bacillus  of  tubercu- 
losis has  been  shown  by  Hansen  in  1871 
to  be  the  exciting  cause  of  leprosy.  The 
labors  of  Neisser  have  confirmed  Han- 
sen's discovery.  The  bacillus  lepras  is 
a  long  and  slender,  motionless  rod,  with 
slightly-tapering  ends.  It  reacts  in  the 
same  way  that  the  tubercle  bacillus  does 
to  coloring  reagents,  but  much  more 
readily — a  distinctive  feature — and'  takes 
aniline  dyes,  which  tubercle  bacilli  do 
not.  Again,  the  bacilli  of  leprosy  arc 
usually  much  more  numerous. 

Literature  of  '96-'97-'98. 

Method  adopted  and  now  advocated 
for  bacteriological  diagnosis  of  leprosy  is 
exceedingly  simple.  a  cover-slip  is 
smeared  with  a  drop  of  the  serum  ob- 
tained by  scraping  one  of  the  leprosy- 
nodules.  This  is  stained  witli  carbol- 
fuchsin  and  decolorized  with  sulphuric 
acid  and  methylene  -  blue  (Gabbett's 
fluid).  11  may  then  be  examined  under 
the  microscope. 

In  tuberculous  lesions  of  the  skin  the 
bacilli  are  always  very  scanty,  and 
usually  only  a  few  are  found  in  the  en- 
tire cover  slip:  but  in  Lepra  each  micro- 
scopic field  shows  enormous  numbers  of 
them.  The  lepra  bacilli  also  readily  -lain 
by  the  simple  aniline  dyes,  while  tubercle 
bacilli  do  not.  In  choosing  a  nodule  from 
which  to  take  the  specimen,  it  is  desirable 


to  select  one  in  an  early  stage  of  develop- 
ment, before  much  scarring  has  taken 
place.  Johnston  and  Jamieson  (Montreal 
Med.  Jour.,  Jan.,  '97). 

The  bacillus  of  leprosy  is  found  in  all 
cases,  but  reliable  cultures  have  not  been 
obtainable  so  far;  while  experimental 
inoculations,  as  previously  stated,  have 
given  no  results.  Still,  fragments  of 
nodules  introduced  into  a  rabbit's  eye 
by  Melcher  and  Ortmann  caused  devel- 
opment of  the  disease  in  the  animal  and 
death.  Arning  thought  he  had  success- 
fully inoculated  a  condemned  criminal 
with  matter  obtained  directly  from  a 
leper,  but  the  subject  was  subsequently 
found  to  belong  to  a  family  (including 
his  son  and  nephew)  in  which  the  dis- 
ease existed:  a  fact  demonstrating  his 
proclivity  to  the  disease. 

[Arning's  case  seems  to  show  that  pre- 
vious inoculation  experiments  in  man 
were  negative  because  the  subjects  were 
in  sufficiently  good  health  to  antagonize 
the  influence  of  the  pathogenic  germ. 

This  would  suggest  that  a  subject  ren- 
dered susceptible  by  the  various  factors 
capable  of  inducing  adynamia  could 
temporarily  become  liable  to  infection 
when  exposed  to  the  disease,  and  remain 
so  as  long  as  his  physical  debility  would 
last.  Even  under  these  circumstances  the 
period  of  incubation  could  be  a  prolonged 
one.    C.  E.  de  M.  Sajous.] 

The  introduction  of  the  virus  through 
abrasions,  scarification  with  medicinal 
substances  and  vaccination,  which  to- 
gether represented  almost  one-fourth  of 
the  etiological  factors  noted  by  Chew  in 
his  1034  cases,  demonstrates  thai  trans- 
mission by  inoculation  is.  in  reality,  an 
important  factor  in  the  pathogenesis  of 
the  disease. 

The  bacilli  are  to  be  found  in  all  tis- 
sues and  Liquids  of  diseased  areas  only, 
and  particularly  in  the  Lepromata, 

[Repeated    examinations    have  failed 
to  show  bacillus  lepra  in  the  blood-cur- 


LEPROSY.  PROPHYLAXIS. 


359 


rent  of  lepers,  excepting  in  the  immedi- 
ate neighborhood  of  lesions.  Arthur 
Van  Harlingen,  Assoc.  Ed.,  Annual, 
'92.] 

Lepromata  found  to  contain  large  num- 
bers of  bacilli.  In  recent  cases  the  bacilli 
are  almost  all  present  in  the  cellular 
elements.  Later  they  multiply,  forming 
a  globular  mass,  and  the  cell  becomes 
gradually  destroyed,  freeing  the  bacilli. 
With  the  juice  of  a  cutaneous  non-ulcer- 
ated leproma,  inoculations  made  on  blood- 
serum  and  on  glycerin-agar,  the  tubes 
being  kept  at  a  temperature  of  98.G°  F. 
Cultures  developed  in  all  the  tubes. 
Growth  was  arrested  at  68°  to  77°  F. 
Gianturco  (Gior.  del  Assoc.  Napolitana 
di  Med.,  etc.,  '91). 

In  general,  the  bacilli  develop  at  the 
same  time  in  the  fixed  cells  of  the  con- 
nective tissue  and  the  migratory  cells. 
The  proliferation  of  the  cells  is  remark- 
ably slow,  notwithstanding  the  great 
number  of  bacilli,  and  is  not  induced  in 
their  immediate  vicinity;  in  the  periph- 
ery of  the  bacillar  foci  the  tissue  is 
healthy.  In  the  cells  the  bacilli  multiply 
more  and  more  and  there  finally  form 
small,  brownish,  globular  masses,  in 
which  the  bacilli  are  very  numerous  and 
close  to  one  another.  At  this  stage  the 
softening  of  the  leprous  nodules  begins, 
the  degenerative  evolution  of  which  thus 
differs  decidedly  from  the  caseous  degen-' 
eration  of  tubercle.  Lie  (Archiv  f.  Derm, 
u.  Syph.,  B.  29,  H.  3,  '95). 

Literature  of  '96-'97-'98. 

The  bacillus  is  demonstrable  in  the 
macules;  the  macules  are  of  the  same 
histo-pathological  structure,  whatever 
their  clinical  form;  through  gradual 
stages  the  macules  may  pass  into  fully 
developed  nodules,  having  the  same  na- 
ture as  the  nodules. 

In  the  early  diagnosis  of  this  disease 
the  possibility  of  demonstrating  the  bacil- 
lus is  of  great  importance.  J.  Darier 
(Ami.  de  Derm,  et  de  Syph.,  vol.  viii,  No. 
12). 

Leprosy  is  contagious  only  after  a  very 
intimate  and  long-continued  intercourse. 
Autoinfection  within  the  body  takes 
place  by  dissemination  of  the  bacilli 
through  the  muscular  system.     E.  Baelz 


(Berliner  klin.  Woch.,  vol.  xxxv,  Nos.  46 
and  47) . 

Lepra  bacilli  demonstrated  upon  the 
skin  in  cases  of  leprosy  with  cutaneous 
manifestations.  The  bacilli  are  absent 
from  the  skin  when  cutaneous  manifesta- 
tions are  wanting.  Gravagna  (Riforma 
Med.,  No.  138,  '96). 

Secretions  and  tissues  of  a  case  of  lep- 
rosy examined;  bacilli  found  in  the 
blood  of  diseased  tissue,  sweat,  epidermis, 
and  sperm,  but  not  in  the  blood  of 
healthy  tissues,  in  the  urine,  or  sputum. 
Faber  (Deut.  med.  Woch.,  June  1,  '97). 

In  cases  with  tubercles  the  bacilli  are 
found  in  many  tissues  of  the  body,  while 
in  those  without  tubercles  they  are  con- 
fined to  the  nerves.  In  the  anaesthetic 
forms  the  bacilli  cease  to  exist  after  a  few 
years.  Many  cases  will  present  no  bacilli 
at  the  end  of  three  or  lour  years.  The 
tubercular  forms  are  the  only  ones  con- 
cerned in  spreading  the  disease.  S.  P. 
Impey  (Lancet,  Sept.  25,  '97). 

The  blood  of  lepers  in  various  stages 
of  the  disease  was  carefully  studied  by 
Winiarski.  When  leprosy  has  not  given 
rise  to  great  changes  in  the  organism, 
the  composition  of  the  blood  is  not  much 
altered.  No  change  in  its  composition, 
in  the  various  forms  of  leprosy  (anaes- 
thetic, nodose,  and  mixed)  could  be  dem- 
onstrated. In  chronic  cases  the  number 
of  blood-corpuscles  was  always  found  to 
be  diminished,  on  an  average,  17.9  per 
cent,  in  men  and  12.3  per  cent,  in 
women.  The  haemoglobin  was  decreased, 
on  an  average,  6.3  per  cent,  in  men  and 
2.4  per  cent,  in  women.  The  white 
blood-corpuscles  were  usually  normal  in 
quantity.  In  all  cases  of  leprosy  a  large 
preponderance  of  multinuclear  leuco- 
cytes was  noted. 

Prophylaxis.  —  At  the  International 
Conference  on  Leprosy,  held  in  Berlin 
in  1897,  the  conclusions  reached  were 
the  following:  (1)  the  leprosy  bacillus 
discovered  by  Hanson  is  the  true  cause 
of  the  disease;  (2)  man  is  the  only  ani- 
mal in  which  that  bacillus  exists;  (3) 


3G0 


LEPROSY.  PROPHYLAXIS. 


leprosy  is  contagious,  but  is  not  an 
hereditary  disease;  (4)  isolation  of  lep- 
rous patients  is  desirable,  and  under  such 
circumstances  as  exist  in  Norway;  (5) 
compulsory  isolation  is  to  be  recom- 
mended. 

Results  of  segregation  in  Norway:  In 
1856  there  were  2871  lepers  in  Norway 
and  now  there  are  hardly  800. 

In  all  countries  where  leprosy  is  met 
with  endemically,  isolation  has  proved 
the  most  useful  method  of  preventing  the 
spread  of  the  disease.  The  worse  the 
social  relations,  the  greater  is  the  danger 
from  contagion.  Hansen  (Monats.  fur 
prak.  Derm.,  B.  25,  No.  9). 

That  segregation  is  an  effective  pro- 
phylactic measure  for  the  protection  of 
the  public  at  large  against  leprosy  is 
undoubted.  The  same  statement  would 
be  applicable,  however,  were  syphilitic, 
tuberculous,  and  other  infectious  sub- 
jects to  be  compulsorily  isolated  and 
ostracized  from  society.  Indeed,  it  would 
apply  more  forcibly,  since  all  the  evi- 
dence at  our  disposal  tends  to  prove  that 
leprosy  is  one  of  the  least  contagious  of 
infectious  disease,  though  undeniably  so 
in  predisposed  individuals. 

A  handsome  young  lady  of  good  family 
married  a  leper,  and  lived  with  him  eight 
years.  Partly  through  jealousy  on  his 
part,  and  partly  through  devotion  on 
hers,  they  made  every  effort  to  share  the 
leprosy  in  common.  The  leprous  husband 
caused  her  to  kiss  his  ulcerated  tongue 
constantly,  and  numerous  attempts  at 
inoculation  were  made.  Nevertheless, 
the  husband  finally  died  of  leprosy,  while 
the  widow  still  lives  in  perfect  health. 
Zambaco  ("Des  Affections  Nerveuses 
Syphilitiques,"  '62). 

Of  the  156  Norwegian  lepers  settled  in 
Minnesota,  only  12  or  14  are  now  dead. 
It  is,  indeed,  strange  that  these  lepers 
have  not  communicated  the  disease  by 
heredity  or  contagion.  It  is  because  their 
habits  in  the  old  country  were  so 
slovenly,  and  because  they  herded  to- 
gether; whereas,  in  America  they  be- 
come cleanly  and  live  a  less  promiscuous 


life.  Each  of  the  lepers  personally  seen 
in  Minnesota  had  his  own  bed  and  his 
own  room.  A.  Hansen  (Edinburgh  Med. 
Jour.,  June,  '91). 

[Kuusamo,  Finland,  was  for  a  long 
time  a  small,  but  obstinate,  focus  for  lep- 
rosy, 16  deaths  having  occurred  between 
1774  and  1800,  and  22  between  1800  and 
1828.  In  1807  the  lepers  were  isolated, 
and  remained  thus  until  1845,  when  the 
hospital  system  was  abolished,  and  the 
lepers  were  visited  twice  a  year  in  their 
own  houses  by  the  medical  officer  of  the 
district.  After  1865  no  further  reports 
were  presented,  and  in  1871  the  medical 
officer  reported  that  he  was  unable  to 
find  any  more  cases  of  leprosy  in 
Kuusamo.  Walter  Wyman,  Assoc.  Ed., 
Annual,  '92.] 

Literature  of  '96-'97-'98. 

Some  of  the  victims  at  D'Arcy  Island 
were  removed  from  white  homes  where 
they  were  employed  as  cooks,  yet  no 
whites  in  the  city  here  ever  contracted 
it.  Ernest  Hall  and  John  Nelson  (Do- 
minion Med.  Monthly  and  Ontario  Med. 
Jour.,  Dec,  '98). 

The  bacilli  of  leprosy  are  only  found 
in  diseased  tissues  and  in  the  blood,  dis- 
charges, etc.,  of  the  latter.  It  is  a  ques- 
tion, therefore,  whether  the  healthy  areas 
of  skin  and  mucous  membrane  are  not 
subject  to  reinfection  from  external 
causes  (see  Etiology)  capable  of  induc- 
ing the  disease  in  any  predisposed  sub- 
ject. 

[Autoinfection  in  chancroid  offers  a 
precedent  of  this  kind,  although  no  spe- 
cific germ  is  at  present  thought  to  act  as 
intermediary.  Even  in  true  syphilis  well- 
authenticated  cases  of  autointoxication 
have  been  observed. 

Reinfection  in  syphilis  tends  likewise 
to  sustain  the  view  that  reinfection  in 
leprosy  is  quite  possible.  A  series  of  cases 
accurately  reported  by  trustworthy  ob- 
servers have  led  Horovitz  (Allg.  Wiener 
med.-Zeit.,  Sept.,  '03)  to  conclude  that 
"the  doctrine  that  there  can  be  no  recur- 
rence in  syphilis  has  been  forever  re- 
futed."'  In  all  the  cases  reviewed  at  least 


LEPROSY.  PROPHYLAXIS. 


361 


the  secondary  manifestations  had  re- 
curred. 

Successful  inoculation  experiments 
were  performed  by  Bouley  (Jullien, 
"Maladies  Veneriennes,"  Paris,  '85). 
This  author  inoculated  a  patient  suffer- 
ing from  tertiary  manifestations;  a 
chancre  resulted,  followed  thirty  days 
later  by  general  manifestations.  These 
experiments  were  successfully  repeated 
by  Horand.  Wallace  also  obtained  by  in- 
oculation a  chancre  in  a  case  of  secondary 
syphilis.  A  large  number  of  cases  could 
be  cited  in  support  of  the  contention  that 
even  in  syphilis  immunity  is  not  invari- 
ably acquired  through  the  first  infection. 

Considering  (1)  the  slow  progress  of 
the  bacillus  leprosse  through  the  tissues, 
(2)  the  fact  that  diseased  regions  alone 
contain  the  organism,  and  (3)  that  the 
general  blood-stream  contains  no  bacilli, 
the  belief  seems  warranted  that  the  un- 
infected areas  of  a  leper  are  liable  to  con- 
tamination, through  solutions  of  con- 
tinuity of  the  mucous  surfaces  or  of  the 
skin,  epithelial  denudation,  absorption 
into  the  gastro-intestinal  canal,  etc., 
when  brought  into  contact  with  leprosy 
bacilli  of  external  origin. 

The  natural  history  of  the  organism  is 
not  sufficiently  known  to  warrant  for  this 
view  more  than  the  position  of  a  working- 
hypothesis.    C.  E.  de  M.  Sajous.] 

Segregation  within  a  restricted  district 
under  such  circumstances  would  greatly 
compromise  the  chances  of  recovery  of 
the  sufferers  so  segregated.  Constantly- 
exposed  to  contaminated  soil  and  sur- 
roundings, reinfection  would  seal  the 
doom  of  many  who,  under  the  influence 
of  hygienic  surroundings,  would  be  re- 
stored to  health  by  appropriate  treat- 
ment. Lazarettos,  pest-houses,  etc., 
would  thus  become  foci  of  infection. 

It  is  probable  that  the  mouth  and  nasal 
cavities  are  the  avenues  of  entrance  of 
the  bacillus  leprosse.  Leprosy  is  con- 
tagious, but  not  hereditary.  Hansen 
(Monats.  f.  prak.  Derm.,  B.  25,  No.  9). 

This  is  strongly  sustained  by  the  fact 
that  in  such  institutions  practically  all 
the  patients  die  of  the  disease  or  its  com- 


plications, while,  among  lepers  only  ex- 
posed to  the  average  contaminating  in- 
fluences of  cities,  many  are  saved. 

Literature  of  '96-'97-'98. 

Of  1034  cases  of  leprosy  observed  dur- 
ing a  period  of  14  years  and  9  months, 
422  have  been  cured  of  their  loathsome- 
ness, while  medicines  failed  to  make  any 
lasting  impression  on  the  remaining  612. 
R.  S.  Chew  (Med.  Age,  Dec.  27,  '98). 

According  to  Morrow's  computation, 
the  number  of  lepers  in  the  Molokai  set- 
tlement (Hawaii)  averages  about  1200, 
but  he  contends  that,  notwithstanding 
the  optimistic  view  of  the  health  author- 
ities that  leprosy  is  on  the  decrease,  the 
annual  consignment  of  lepers  to  the  set- 
tlement shows  but  little,  if  any,  diminu- 
tion. "All  the  indications  point  to  the 
existence  of  a  vast  deal  of  latent  leprosy, 
which,  as  the  disease  develops  into  a 
recognizable  form,  must  continue  for 
many  years  to  come  to  furnish  a  con- 
stantly-recurring series  for  the  leper 
colony." 

What  probably  does  exist  in  Hawaii 
is  a  large  number  of  vulnerable  individ- 
uals, vulnerable  through  the  operation  of 
the  various  factors  enumerated,  and  espe- 
cially active,  in  our  new  possession,  on 
account  of  the  deteriorated  state  of  the 
natives.  These  etiological  factors,  as 
well  as  susceptible  subjects,  are  to  be 
found  in  all  countries  and  especially  in 
districts  where  poverty,  filth,  bad  food, 
and  alcoholism  prevail.  Were  compul- 
sory isolation  abandoned,  therefore,  lep- 
rosy— like  syphilis,  tuberculosis,  cancer, 
etc. — would  assume  the  position  of  a 
general  disease,  its  development  being 
commensurate  with  its  low  degree  of 
contagiousness  and  the  hygienic  level 
and  customs  of  the  communities  exposed. 
In  the  United  States  the  debilitating 
influence  of  excessive  and  unduly  pro- 
longed  physical   and   mental  activity 


362 


LEPROSY.  PROPHYLAXIS. 


would  tend  to  increase  vulnerability,  and 
the  dissemination  of  leprosy  might  thus 
be  greatly  enhanced. 

Literature  of  '96-'97-'98. 

In  all  countries  where  leprosy  has  be- 
come epidemic  its  advance  is  insidious; 
it  spreads  slowly,  and,  before  the  health 
authorities  awaken  to  a  realization  of  the 
danger,  it  has  made  such  headway  that 
its  further  progress  cannot  be  arrested. 
Morrow  (N.  Y.  Med.  Jour.,  Nov.  7,  '96). 

Segregation  of  lepers  is,  therefore, 
imperative,  but  only  on  the  condition 
that  they  be  compensated  for  their  isola- 
tion on  behalf  of  others  b}^  adequate  pro- 
tection against  continued  infection  and 
by  the  most  conscientious  efforts  to  re- 
store them  to  health  and  to  their  fami- 
lies. 

Literature  of  '96-'97-'98-'99. 

According  to  Brocq,  the  first  leper,  a 
Chinese  coolie,  was  discovered  in  the 
vicinity  of  Honolulu  in  1853.  Eight  years 
later  several  lepers  were  found  among 
his  associates,  and  twenty  years  after 
this  (1880)  with  a  population  of  44,000 
people,  there  were  2000  lepers  upon  the 
Hawaiian  Islands  (statistics  of  Wood, 
White,  and  Tyson). 

A  leprous  fisherman,  who  came  from 
San  Mauritius  to  the  Island  of  Rodri- 
guez, infected  this  place.  The  island  of 
Pinez  was,  according  to  Fourne,  infected 
by  prisoners  brought  from  New  Cale- 
donia. Eight  years  later  the  disease 
broke  out  among  the  natives. 

Zuranga  reports  that  a  leprous  sailor, 
while  visiting  in  Parcent,  infected  the 
friend  and  the  brother  of  the  friend  with 
whom  he  was  stopping.  The  former  in- 
fected a  friend,  who,  in  his  turn,  infected 
a  number  of  his  acquaintances. 

Fourne  found  that  Toured,  a  village 
near  Nice,  was,  up  to  1850.  free  from 
leprosy.  During  this  year,  the  family, 
M..  engaged  a  leprous  servant,  and  fol- 
lowing this  both  M.  and  his  wife  con- 
tracted the  disease;  subsequently  in  the 
family  G.,  with  whom  the  M.'s  had  asso- 
ciated, a  cousin  of  the  family  C.  his  wife 
and  three  children,  became  affected. 


Ghose  saw  a  case  in  which  the  wife  be- 
came infected  by  her  husband.  After  the 
death  of  her  husband  she  returned  to  her 
former  home,  a  village  free  from  leprosy, 
where  she  lived  in  the  house  of  her 
brother.  The  brother  became  affected; 
and  during  the  next  six  years  three  per- 
sons in  the  neighborhood. 

The  infection  of  physicians  and  clergy- 
men in  contact  with  lepers  (Dr.  Robert- 
son, Father  Damien,  Father  Boglioli, 
Pastor  Becker,  etc.)  are  well  known. 
These  cases  are  only  a  few  of  the  great 
many  which  can  be  found  in  the  litera- 
ture. Those  mentioned  are  particularly 
conclusive  and  direct.  E.  O.  Jellinek 
(Progress  of  Med.,  Feb.  1.  '99). 

In  some  "settlements/'  "lazarettos," 
or  "pest-houses"  these  unfortunate  pa- 
tients (some  of  which  may  not  be  leprous 
and  be  suffering  from  tuberculosis,  sy- 
ringomyelia, or  syphilis)  are  practically 
assimilated  to  criminals  awaiting  the 
death-penalty,  while  neglect,  both  gen- 
eral and  professional,  is'  insidiously  act- 
ing as  executioner. 

Literature  of  '96-'97-'9$. 

About  a  league  off  the  eastern  coast  of 
Vancouver  Island,  and  separated  from  it 
by  the  waters  of  the  Gulf  of  Georgia,  lies 
the  pretty  little  island  of  D'Arcy.  .  .  . 
Hidden  away  in  their  little  cabins  under 
the  grateful  shade  of  the  fir,  with  their 
hot  blood  burning  out  their  lite,  the  vic- 
tims of  this  plague  are  slowly  dying  with 
their  faces  to  the  rising  sun.    .    .  . 

Following  the  policy  of  isolation,  most 
notably  exemplitied  at  Molokai.  in  Ha- 
waii, and  also  adopted  at  the  Tracadie 
Lazaretto,  in  eastern  Canada,  the  Vic- 
toria City  Council,  eight  years  ago.  re- 
moved the  victims  to  D'Arcy  Island, 
where  a  line  of  huts,  all  under  one  roof, 
were  erected  for  their  accommodation. 
.  .  .  Here  the  unfortunate  sufferers 
are  regularly  supplied  with  rations  and 
properly  provided  for  without  imperil- 
ing public  health.  .  .  .  Every  thrrr 
month*  the  sanitary  officer  of  the  city 
of  Victoria  visits  the  settlement  with  a 
sufficient  supply  of  food  for  the  following 
quarter.    .    .  . 


LEPROSY.  PROPHYLAXIS. 


363 


As  our  dory  grates  on  the  shore,  and 
we  hurry  up  the  incline  to  their  homes, 
the  real  wretchedness  of  their  condition 
becomes  evident.  .  .  .  Every  develop- 
ment and  every  type  of  this  loathsome 
disease  is  apparent,  in  the  little  group  be- 
fore us.    .    .  . 

The  monotony  of  the  existence  of  these 
unhappy  creatures  can  hardly  be  de- 
scribed. No  change  in  its  recurring  mis- 
eries is  noticeable  save  the  transforma- 
tion which  comes  over  their  little  world 
with  the  return  of  the  seasons.    .    .  . 

Since  the  establishment  of  the  station 
only  one  white  man  has  been  incarcerated 
upon  it.  He  was  shunned  by  his  Mon- 
golian fellow-sufferers,  and,  as  in  a  com- 
munity of  this  kind,  the  patients  are 
dependent  upon  one  another  for  mutual 
assistance,  the  white  victim  speedily  sank, 
from  neglect  and  loneliness.    .    .  . 

The  station  is  maintained  on  the  prin- 
ciple of  the  strong  helping  the  weak  (  ! ) . 

The  supplies,  including  the  coffins*  are 
placed  in  a  storehouse,  and  each  man 
helps  himself  as  necessity  requires. 
Ernest  Hall  and  John  Nelson  (Dominion 
Med.  Monthly  and  Ontario  Med.  Jour., 
Dec,  '98). 

[*AU  italics  are  mine.  C.  E.  de  M. 
Sajous.] 

Such  neglect  on  the  part  of  munici- 
palities —  such  wretchedness  —  is  not 
compatible  with  modern  civilization. 
Sanitary  regulations  to  protect  com- 
munities involving  the  sequestration  of 
innocent  sufferers  should  not  destroy 
with  one  hand  to  save  with  the  other. 
All  should  come  in  for  their  share  of 
the  benefits,  if  equity  is  to  prevail  and 
if  the  cruelties  of  the  dark  ages  are  not 
to  be  perpetuated.  Consumptives,  in- 
ebriates, the  insane,  etc.,  enjoy  all  the 
advantages  of  well-appointed  and  com- 
fortable sanatoria;  so  should  the  leper 
receive  his  share  of  all  that  human  com- 
passion can  afford  to  relieve  him  of 
physical  sufferings  and  of  the  mental 
torture  that  ostracism  entails. 

A  sanatorium  for  lepers  should,  in  the 
light  of  our  present  knowledge,  he  eon- 


ducted  much  on  the  same  lines  as  one 
for  consumptives:  scrupulous  cleanli- 
ness, pure  air  and  sunlight,  strict  atten- 
tion to  the  destruction  by  fire  or  antisep- 
tics of  all  substatices  containing  bacilli, 
especially  the  secretions  of  the  mouth 
and  nose  and  the  discharges  originating 
from  tuberculous  nodules.  With  abun- 
dant wholesome  food,  comfortable  sur- 
roundings, distraction,  and  constant  pro- 
fessional care,  the  lives  of  these  victims 
could  be  made  bearable;  the  fetters 
which  sanitary  rulings  impose  upon  them 
would  hardly  be  felt,  and  many  would 
be  returned  to  their  homes. 

[At  the  Leper  Hospital  of  Maracaibo 
(Venezuela),  in  charge  of  Dr.  Flores,  a 
very  laudable  effort,  sustained  by  the 
government  and  private  initiative,  to 
render  the  life  of  these  unfortunates 
bearable,  has  been  made.  The  success 
met  with  is  thus  described  by  our  faith- 
ful consul  in  that  city,  Hon.  E.  H. 
Plumacher,  who  has  repeatedly  visited 
the  sufferers  and  inquired  into  their 
general  welfare:  — 

"The  interior  arrangements  of  the 
island  are  excellent.  Capacious  cisterns 
insure  a  supply  of  fresh  water,  and  the 
diet  is  wholesome  and  abundant,  the  cost 
of  the  maintenance  and  treatment  of  each 
person  amounting  monthly  to  about 
thirteen  dollars  in  American  money.  A 
comfortable  building  has  been  erected  for 
the  use  of  the  employees,  while  for  the 
patients  a  large  edifice,  built  of  concrete, 
forming  a  parallelogram  with  a  court- 
yard in  the  centre,  is  divided  into  sepa- 
rate apartments,  plainly,  but  sufficiently 
furnished.  A  neat  chapel  has  been  re- 
cently built,  where  religious  service  is 
held  every  Sunday.  A  pleasant  feature 
is  the  establishment  of  cottages  with 
grounds,  in  which  reside  those  patients 
whose  means  permit  of  it.  Land  is  given 
free  to  anyone  who  is  able  to  erect  a 
dwelling,  and,  as  there  are  many  who 
possess  an  income,  lit  He  homesteads  arc 
soon  formed. 

"It  was  at  first  a  mooted  point  as  to 
whether  marriages  should  be  permitted 
among  patients,  hut  the  question  was  de- 


3G4 


LEPROSY.  TREATMENT. 


cided  affirmatively,  and  several  weddings 
took  place.  For  years  the  theory  of 
sterility  was  not  contradicted  by  experi- 
ence, and  seemed  about  to  be  definitely 
settled,  when  two  births  occurred  on  the 
island,  the  parents  in  each  case  being 
lepers.  I  would  be  inclined  to  ask 
whether  a  mistake  had  not  been  made 
in  the  diagnosis  of  one  or  the  other  of  the 
parents,  confounding  with  true  leprosy 
some  other  physical  taint. 

"With  the  establishment  of  matri- 
monial relations  and  the  system  of  sepa- 
rate cottages  for  those  who  desire  them, 
the  island  is  beginning  to  assume  the  as- 
pect of  a  rural  municipality.  Its  extent 
is  little  more  than  a  mile  square,  with 
good  soil,  of  which  advantage  has  been 
taken  by  the  well-to-do  patients  for  the 
cultivation  of  various  products  and  the 
breeding  of  goats.  The  territory  has 
been  artificially  stocked  with  game,  which 
is  now  becoming  abundant,  and  nothing 
seems  to  have  been  omitted  to  secure  the 
comfort  and  welfare  of  the  unfortunates. 
A  library  is  at  their  constant  disposal, 
and  occasional  musical  entertainments 
are  furnished  by  the  Junta,  whose  efforts 
seem  directed  to  the  establishment  of  a 
veritable  home  for  the  patients,  where 
they  may,  as  far  as  possible,  forget  their 
afflictions  and  pass  their  lives  in  cheer- 
fulness. Weekly  visits  of  relatives  and 
friends  are  allowed,  which  are  looked  for- 
ward to  with  eager  anticipation,  and  the 
discipline  generally  is  mild  and  judi- 
cious."   C.  E.  de  M.  Sajous.] 

As  to  the  immigration  of  lepers  into 
the  country,  Dr.  Bracken,  of  Minne- 
apolis, basing  his  opinion  upon  a  study 
of  the  Minnesota  colony,  suggests  that 
the  family  history  of  all  immigrants 
from  a  country  where  leprosy  prevails 
should  be  secured  before  they  are  allowed 
to  embark  for  America,  no  member  of  a 
leprous  family  being  permitted  to  land 
upon  our  shores.  This  procedure  would 
doubtless  prove  effective  were  it  properly 
carried  out;  but,  as  recently  shown  by 
Hansen,  in  answer  to  Ashmead,  who 
recommends  the  same  measure,  the  symp- 
tomatology of  the  disease  in  its  early 


stages  and  the  necessity  of  examining  the 
entire  body  of  each  passenger  would  de- 
feat any  attempt  in  this  direction  from 
the  start. 

The  conditions  antagonistic  to  the 
spread  of  leprosy  in  Minnesota  are  also 
opposed  to  sterility,  as  borne  out  by  the 
families  of  several  of  the  Minnesota  lep- 
ers. Dr.  Bracken  believes  it  quite  pos- 
sible for  leprosy  to  die  out  in  certain 
favored  sections  of  the  country,  such  as 
Minnesota,  without  segregation,  provided 
the  importation  of  lepers  is  discontinued; 
but  he  contends  that  segregation  should, 
nevertheless,  be  insisted  upon  in  all  cases. 

Treatment. — If,  as  is  now  believed  by 
Morrow,  Hansen,  Sticker,  and  others, 
"the  vehicles  of  the  virus  through  which 
contagion  is  affected  in  the  vast  majority 
of  cases  are  the  secretions  of  the  mouth 
and  nose,"  while  "the  port  of  entrance  is 
the  mucous  membrane  of  the  respiratory 
and  intestinal  tract  with  secondary  in- 
fection through  the  blood  or  lymphatic 
system"  (Morrow),  attention  to  the  nasal 
cavities,  the  mouth,  and  throat  is  of 
primary  importance. 

Literature  of 

Attention  drawn  to  the  importance  of 
the  nasal  treatment,  not  only  on  account 
of  the  patient  himself,  but  also  in  order 
to  prevent  the  spread  of  the  disease. 
Sticker  (Munch,  med.  Woch.,  Xos.  39  and 
40,  '97). 

The  normal  secretions  of  the  nasal 
cavities  are  alkaline  and  of  a  higher  spe- 
cific gravity  than  water;  hence,  the  use 
of  the  latter  as  detergent  is  painful  and 
irritating  to  the  mucous  membrane. 
Any  liquid  used  for  this  purpose  should 
at  least  possess  the  alkalinity  and  specific 
gravity  represented  by  1  drachm  of  com- 
mon salt  to  1  pint  of  water.  As  a  wash, 
the  following  mixture  can  be  confidently 
recommended  after  extensive  trial  in  dis- 
orders of  the  upper  respiratory  tract: — 


LEPROSY.  TREATMENT. 


365 


^  Borate  of  sodium, 

Bicarbonate  of  sodium,  of  each,  1/2 
drachm. 

Fluid  extract  of  Canadian  pine,  1 

drachm. 
Glycerin,  2  drachms. 
Water,  1  pint. — M. 

This  may  be  used  with  an  atomizer 
producing  a  coarse  spray  night  and 
morning,  the  cavities  being  thoroughly 
drenched.  In  large  colonies  under  mu- 
nicipal management  borax  and  bicarbo- 
nate of  sodium,  equal  parts,  may  be  pro- 
cured in  bulk  and  dealt  out  to  patients 
with  instructions  to  use  1  teaspoonful  of 
the  powder  to  a  pint  of  lukewarm  water. 
An  economical  way  is  to  inhale  the  solu- 
tion from  the  hand,  using  the  latter  as 
scoop.  When  ulceration  is  present,  the 
local  treatment  for  syphilitic  rhinitis 
(q.  v.)  is  indicated.  The  secretions,  as 
already  stated,  should  be  destroyed,  and 
the  use  of  spit-cups  rigidly  enforced. 

Segregation  where  lepers  have  pre- 
viously lived  without  resorting  to  such 
precautions  should  be  avoided. 

Cleanliness  of  the  surface  should  be 
carried  to  its  maximum  possibility  com- 
patible with  the  patient's  strength.  As 
a  curative  measure,  Baelz,  of  Tokio,  rec- 
ommended 3  to  5  strong  mineral  baths 
at  45°  to  53°  C.  a  day  for  a  period  of 
about  one  month.  His  results  were  ex- 
cellent. Sea-bathing  was  extensively 
used,  and  with  marked  advantage,  dur- 
ing the  early  part  of  the  century.  At 
first  warm  sea-water  baths  were  given, 
until  all  "scaly  incrustations"  were  re- 
moved; after  this  "a  cure  was  soon  ob- 
tained, especially  in  young  persons,  by 
bathing  in  the  open  sea"  (Willan). 

Among  the  internal  remedies  recom- 
mended by  dermatologists,  chaulmugra- 
oil  (see  description  in  volume  ii)  may 
be  said  to  hold  the  first  place.  The  re- 
sults obtained  from  its  use  have  been 


varied,  but,  assisted  by  the  prophylactic 
measures  outlined  above,  its  usefulness 
will  probably  be  vastly  increased.  It  has 
been  administered  in  doses  of  from  10 
to  200  drops.  By  beginning  with  small 
doses  and  gradually  increasing  the  quan- 
tity given,  the  gastric  disorders  occa- 
sionally following  its  use  may  generally 
be  avoided  or  at  least  retarded  until 
active  benefit  is  procured.  It  is  borne 
more  easily  by  lepers  than  by  healthy 
subjects,  and  its  use  can  be  continued 
years,  if  need  be.  Many  cases  have  been 
reported  in  which  permanent  cure  had 
been  obtained. 

Tonics  may  be  given  at  the  same  time. 
These  agents,  especially  arsenic  and 
strychnia,  are  of  practical  importance  by 
tending  to  overcome  the  general  ady- 
namia. 

Experiments  upon  18  patients  as  to 
value  of  chaulmugra-oil  show  increase  of 
perspiration,  decrease  of  tubercles,  im- 
proved appetite  and  sense  of  well-being, 
increase  of  sensation  and  increased  sup- 
pleness of  skin,  and  lessening  of  pains  in 
the  joints.  The  oil  was  not  administered 
in  capsules,  but  drunk  pure.  The  dose 
used  was  V2  to  1  drachm  daily.  Creolin 
used  with  excellent  results,  as  a  palliative 
and  topical  remedy.  Beaven  Rake  ("An- 
nual Report  on  Leprosy  and  the  Trinidad 
Leper  Asylum,"  '90). 

Gurjun-oil,  obtained  from  the  Dip- 
terocarpus  Icevis,  a  tree  growing  in  east- 
ern India,  has  also  been  considerably 
used,  with  varying  results.  It  is  given 
internally  in  capsules  or  in  emulsion  with 
lime-water,  the  dose  of  oil  varying  from 
1  to  3  drachms.  It  is  especially  indicated 
in  the  anaesthetic  form.  The  same  solu- 
tion is  also  applied  over  leprous  sores  as 
a  dressing.  Better  results  have  been  ob- 
tained by  Phillippo,  by  the  use  of  the 
latter  externally  and  chaulmugra-oil  in- 
ternally. 

Ichthyol  has  been  strongly  recom- 
mended by  TJnna,  who  gives  about  10 


36G 


LEPROSY.  TREATMENT. 


grains  a  day  in  divided  doses.  Ichthyol- 
soap  or  the  pure  drug  may  also  be  em- 
ployed locally.  Pyrogallie  acid  and 
chrvsarobin  have  also  been  recommended 

by  TJnna. 

Cure  of  a  Brazilian  leper  by  Unna's 
method.  Both  legs  and  feet  were  rubbed 
with  a  10-per-cent.  pyrogallie-aeid  oint- 
ment, and  the  rest  of  the  body  with  a  10- 
per-cent.  chrvsarobin  ointment,  twice 
daily.  The  face  was  covered  with  a 
strong  creasote  plaster-mull  once  a  day, 
the  jaws,  however,  being  painted  with 
zinc  gelatin.  Later,  the  larger  tubercles 
were  cut  out  and  the  patient  given 
ichthyol  internally.  The  patient  re- 
covered by  the  end  of  two  or  three 
months.  Dreckmann  (Berliner  klin. 
Woch.,  Apr.  29,  '89). 

Crocker  has  recently  used  corrosive 
sublimate  hypodermically.  A  Pravaz 
syringeful  of  the  solution,  varying  in 
strength  according  to  age,  is  injected 
into  the  buttock  once  a  week.  Europhen, 
thyroid  substance,  salicylic  acid,  and 
airol  may  also  be  mentioned  among  the 
remedies  meriting  a  trial, 

[Speaking  of  the  use  of  mercury  in  lep- 
rosy, it  seems  to  me — judging  from  ex- 
perience acquired  in  the  treatment  of 
tuberculosis — that  tonic  doses  of  calomel 
(Vso  grain  three  times  a  day)  should 
prove  advantageous.  (See  Mercury, 
Physiological  Action.)  They  dis- 
tinctly increase  the  number  of  red  blood- 
corpuscles  and  stimulate  nutrition.  C.  E. 
de  M.  Sajous.] 

Europhen  successful  when  given  a  long 
time  every  day  or  every  other  day  sub- 
cutaneously :  — 

R>  Europhen,  7  Y2  grains. 

Oil  of  sweet  almonds.  21/2  drachms. 
Filtered  and  sterilized  during  twenty- 
four   hours.     Goldschmidt    (Revue  de 
Ther.  Medico-Chir..  Jan.  15,  '95). 

Literature  of  '96-'97''9&. 

Two  cases  of  leprosy  treated  by  the 
thyroid-gland  substance  in  both  of  which 
there  was  considerable  improvement  in 
the  local  lesions  and  general  condition. 
C.  B.  Maitland  (Lancet.  Oct.  31.  '96). 


The  following  method  is  recom- 
mended:— 

1.  Local  treatment  with  a  20-per-cent. 
salicylic-acid  salve.  This  is  applied  over 
the  diseased  spots  after  having  been 
rubbed  with  pumice-stone. 

2.  Administration  of  large  doses  of 
oleum  gynocardise,  3  3/4  drachms. 

3.  Strong  mineral-baths,  45°  to  53°  C, 
from  3  to  5  baths  a  day  for  a  period  of 
about  one  month.  E.  Baelz  (Berliner 
klin.  Woch.,  vol.  xxxv,  Nos.  46,  47). 

In  leprosy  inunction  and  injections  of 
airol  (bismuth  oxy-iodogallate)  used. 
The  inunctions  are  of  10-per-cent.  solu- 
tions of  the  drug  in  vaselin.  which  give 
also  the  beneficial  results  from  massage. 
For  injections  into  the  leproma  the  fol- 
lowing formula  is  employed:  Aristol,  5; 
glycerin,  35;  distilled  water,  10.  The 
inunction  is  performed  over  the  whole 
body  at  night;  the  next  morning  the  pa- 
tient takes  a  warm  bath,  and  during  the 
day  the  plaques  and  tubercles  are  in- 
jected. For  the  nose  and  throat  the 
powder  is  insufflated,  or.  in  case  this 
is  not  well  borne,  the  parts  are  painted 
with  the  ointment.  The  drug  is  un- 
doubtedly absorbed  and  enters  the  blood 
as  iodine,  bismuth,  and  gallic  acid,  in  a 
nascent  state.  During  the  early  days  of 
its  administration  by  subcutaneous  in- 
jection there  appear  dyspnoea,  feeble 
heart-action,  and  reversed  gastric  peri- 
stalsis. Later  appears  a  gray  line  at  the 
junction  of  the  gums  with  the  teeth, 
which  is  attributable  to  the  bismuth, 
while  the  other  symptoms  are  caused  by 
the  gallic  acid.  Domenico  Fornara 
(Therap.  Woch..  No.  12.  S.  71.  '97). 

The  therapeutic  qualities  of  the  sinu- 
tree  (the  E.rcoccori  agallocha)  should  be 
investigated  scientifically.  This  plant, 
when  cut.  exudes  a  thick,  milk-white 
juice  that  is  mildly  irritating.  Its  action 
may  either  be  to  produce  a  reactive  in- 
flammation in  the  skin  or  to  kill  the  lepra 
bacilli.  L.  Lewin  (Dent.  nied.  Woch.. 
May  20.  'OS). 

Tuberculous  nodules  may  be  destroyed 
by  galvanocautery  or  thermocautery  fol- 
lowed by  local  antiseptic  lotions.  It'  this 
procedure  is  objected  to,  their  absorption 
may  sometimes  be  obtained  by  local  ap- 


LEPROSY.  TREATMENT. 


367 


plications  of  iodine  or  mercurial  oint- 
ment. Besnier  uses  with  success  in 
tuberculous  cases  a  form  of  treatment 
combining  several  measures. 

Internal  treatment  (chaulmugra-oil, 
up  to  300  drops;  salol,  up  to  5  grammes 
daily)  perseveringly  administered.  Each 
tubercle  is  cauterized  interstitially  by 
means  of  single  or  multiple  points,  or  by 
electrocaustic  bars  when  the  surfaces  to 
be  destroyed  are  large.  After  cauteriza- 
tion should  follow  daily  spraying  with 
weak  carbolic-acid  water  and  dressing 
with  sublimate  or  iodoform  gauze,  to- 
gether with  the  management  of  cicatriza- 
tion by  means  of  nitrate-of-silver  or  zinc 
pencils.  The  same  galvanocaustic  appli- 
cation should  be  made  to  all  affected 
points  of  the  mucous  membranes  of  the 
lips,  nose,  mouth,  tongue,  and  pharynx. 
By  their  means  it  is  quite  easy  to  check 
and  destroy  the  leprous  foci  so  common 
in  all  these  parts,  and  the  results  ob- 
tained are  very  remarkable.  E.  Besnier 
(Univ.  Med.  Mag.;  "Pictorial  Atlas  of 
Skin  Dis.,"  etc.,  Part  IV,  '96). 

In  a  case  successfully  treated  by  Bes- 
nier in  the  manner  just  outlined,  the  pa- 
tient, unknown  to  his  physician,  had 
also  taken  for  a  period  of  three  years 
chlorate  of  potassium,  15  grains  three 
times  a  day.  Interesting  in  this  con- 
nection is  the  following  observation  by 
Carreau,  and  the  results  obtained  by 
Dyer  with  Calmette's  antivenine. 

In  a  leper  who  was  bitten  by  a  rattle- 
snake a  manifest  diminution  of  the  lep- 
rous tubercles  took  place  before  death, 
twenty-four  hours  after  the  bite.  Recog- 
nizing the  fact  that  the  acknowledged 
result  of  inoculation  of  serpent-poison 
was  to  produce  a  condition  of  methsemo- 
globinsemia,  heavy  doses  of  potassium 
chlorate  were  tried  in  several  cases  of 
leprosy.  From  150  to  300  grains  of  the 
drug  were  given  daily  for  three  days, 
producing  grave  symptoms  of  poisoning 
therewith,  hut  after  the  disappearance  of 
these  symptoms  the  leprous  tubercles  al- 
most entirely  disappeared,  leaving  the 
skin  soft  and  wrinkled.  Cancan  (Pro- 
vincial Med.  Jour.,  Mar.  1.  "1)3). 


The  antivenomous  serum  of  Calmette, 
of  Lille,  was  employed  by  Dr.  I.  Dyer, 
of  Xew  Orleans,  in  the  treatment  of 
lepers,  with  promising  results.  It  was 
injected  under  the  skin  with  a  Pravaz 
antitoxin  syringe.  The  dose  varied  from 
15  minims  to  2  1/2  drachms.  The  injec- 
tions were  made  every  second  day  at  first, 
subsequently  every  day.  The  parts  of 
the  body  selected  for  injections  were  in 
the  gluteal  muscles  and  the  skin  in  this 
region,  the  interscapular  spaces,  and,  ex- 
ceptionally, the  leprous  lesions  them- 
selves. 

In  four  out  of  the  five  cases  in  which 
this  procedure  was  resorted  to  marked 
improvement  was  obtained. 

Serum-therapy  has  been  tried  by 
Carasquilla  in  one  hundred  cases  with 
"good  results,"  but  the  method  has  not, 
as  yet,  received  sufficient  trial  to  merit 
more  than  a  mention.  The  same  may 
be  said  of  Merck's  serum,  tubercle-juice, 
and  Coley's  erysipelas  toxins  recently 
tried. 

Literature  of  '96-'97-'98. 

Horses  immunized  with  hlood-serum 
from  lepers  by  injecting  15  to  60  cubic 
•  centimetres  every  ten  days  on  three  occa- 
sions, and  ten  days  after  the  third  injec- 
tion the  serum  is  taken.  The  serum, 
taken  with  great  care,  is  then  employed 
as  follows:  In  a  leper  from  whom  blood 
to  the  amount  of  150  to  250  cubic  centi- 
metres has  been  drawn,  1  to  5  cubic  centi- 
metres of  horse's  serum  is  injected  after 
five  days;  a  second  injection  is  made 
three  or  four  days  later,  according  to  the 
degree  of  reaction,  then  a  third  and  a 
fourth :  in  some  subjects  reaction  does 
not  take  place  till  after  this  period.  The 
reaction  manifests  itself  by  fever,  circu- 
latory disturbances,  changes  in  the  secre- 
tions, etc.  After  some  days  the  leprous 
lesions  undergo  somewhat  rapid  modifi- 
cation: the  tubercles  desquamate  and 
shrink,  the  ulcerations  become  vegetating 
and  cicatrize.  The  disturbances  of  sensi- 
bility are  lessened,  and.  when  the  lesions 


LEPROSY.  TREATMENT. 


are  not  too  far  advanced,  improvement 
takes  place  rapidly,  and  to  an  astonish- 
ing degree.  One  hundred  cases  treated 
by  this  method  with  good  results.  Caras- 
quilla  (Brit.  Med.  Jour.;  Correio  Med. 
de  Lisboa,  xxv,  122,  124,  '96). 

Case  of  maculo-tubercular  leprosy 
treated  with  Carasquilla's  serum. 

Between  February  7  and  June  9,  '97, 
twenty-six  injections  of  serum  were  made 
into  the  buttocks;  0.2  cubic  centimetre 
was  first  used,  and  this  was  increased  up 
to  3  V4  cubic  centimetres.  The  injections 
were  given  at  first  twice  and  then  once  a 
week,  and  later  there  were  at  least  two 
pauses  of  fourteen  days.  A  local  reaction 
occurred,  most  marked  on  the  evening  of 
the  day  of  injection,  and  disappeared  in 
a  few  days.  Usually  there  were  no  un- 
pleasant general  symptoms. 

Redness  and  swelling,  with  subsequent 
absorption,  occurred  in  the  leprous  nod- 
ules, and  there  was  considerable  diminu- 
tion in  the  infiltration  ot  the  tissues.  A 
new  growth  of  hair  appeared  on  the  ex- 
tensive patches  of  alopecia  upon  the  head. 
Leprous  ulcers  in  the  mouth  healed. 
Patient's  condition  underwent,  in  every 
way,  a  marked  improvement.  During  the 
four  months  after  the  injections  there  was 
some  tendency  to  relapse,  but  these  re- 
lapses were  much  milder  than  formerly. 
The  results  obtained  were  much  better 
than  under  any  other  treatment.  Buzzi 
(Brit.  Med.  Jour.;  Deut.  med.  Woch., 
Oct.  14,  '97). 

Merck's  serum  was  employed  about  six 
months.  The  first  patient  received,  in  all, 
eighteen  injections,  and  the  other  twenty, 
and  in  addition  to  these,  each  was  given 
the  serum  on  three  occasions  by  the 
mouth.  The  injections  were  made  into 
the  abdominal  wall  midway  between  the 
anterior  superior  iliac  spine  and  the  linea 
alba.  A  diphtheria-antitoxin  syringe  was 
employed.  The  total  amount  of  serum 
injected  was,  in  the  first  case,  4  ounces 
and  in  the  second  5  ounces.  The  initial 
dose  was  1/2  drachm,  and  the  quantity 
was  gradually  increased  until  2 1/< 
drachms  were  injected  at  once.  Decided 
improvement  took  place  in  both  patients 
under  the  treatment.  Amelioration  per- 
sisted to  the  time  at  which  the  paper  was 
written,  namely:   two  and  a  half  months 


after  the  cessation  of  treatment.  A. 
Grunfeld  (Derm.  Zeit.,  B.  5,  H.  3,  '98). 

Laverde  obtained  a  fluid  by  crushing 
leprous  tubercles,  and  this,  after  mixing 
it  with  sterilized  water,  he  injected.  The 
patients  treated  in  this  manner  improved. 
M.  Hallopeau  (Brit.  Med.  Jour.,  Jan.  22, 
'98). 

Four  cases  of  leprosy  subjected  to  treat- 
ment with  the  toxins  of  erysipelas.  The 
initial  dose  was  one  minim  of  Coley's 
preparation  of  the  toxins  of  erysipelas 
and  of  the  bacillus  prodigiosus,  and  this 
was  gradually  increased  until  near  the 
close  of  the  experiment  in  each  case  a 
dose  of  22  minims  was  reached. 

Conclusions  reached  are:  (1)  injections 
of  the  toxins  of  erysipelas  have  no  effect 
on  the  course  of  leprosy,  and  (2)  the  sys- 
tem may  tolerate  large  and  continued  in- 
jections if  the  dose  is  gradually  increased. 
Henry  D wight  Chapin  (Phila.  Med.  Jour., 
Dec.  31,  '98). 

Beaven  Bake,  of  Trinidad,  has  em- 
ployed nerve-stretching.  He  found  that 
the  great  sciatic  was  the  most  satisfactory 
nerve  to  stretch,  being  near  the  spinal 
ganglion,  while  it  commands  the  supply 
of  the  whole  leg  and  foot  and  the  back 
of  the  thigh.  The  chief  indications  for 
the  operation  are  perforating  ulcer;  some 
cases  of  necrosis;  pain,  whether  asso- 
ciated with  the  perforating  ulcer  or  with 
peripheral  neuritis.  More  or  less  relief 
was  given  in  one-half  the  one  hundred 
cases  operated  upon. 

For  perforating  ulcer  of  the  foot  occur- 
ring in  leprosy,  the  ulcer  is  slit  up  Im- 
perforating the  foot  through  the  bottom 
of  the  ulcer  from  sole  to  dorsum,  and 
then  bringing  out  the  bistoury  between 
the  toes.  The  wound  is  then  stuffed  with 
lint  and  allowed  to  heal  up  from  the  bot- 
tom by  granulation.  Beaven  Rake  ("An- 
nual Report  on  Leprosy  and  the  Trinidad 
Leper  Asylum,"  '90). 

Charles  E.  de  M.  Sajous, 

Philadelphia. 

LEPTOMENINGITIS.  See  Meningi- 
tis. 


LEUKEMIA. 

LEUCORRHCEA.     See  Uterus  and 
Vagina. 

LEUKEMIA. 

Definition. — Leukaemia  is  a  disease 
characterized  by  a  marked  excess  of 
lymphatic  tissue  in  the  body,  by  a  pecul- 
iar excess  of  circulating  white  corpuscles, 
and  wide-spread  and  varied  symptoms  of 
toxaemia,  with  the  frequent  presence  of 
mechanical  symptoms  of  pressure. 

Varieties. — There  are  three  types  of 
the  disease,  considered  from  both  the 
pathological  and  clinical  points  of  view: 
myelogenous,  or  leucocytic;  lymphatic, 
or  lymphocytic;  and  mixed  leukaemia. 
The  myelogenous  and  lymphatic  types 
are  chronic  in  their  course.  The  mixed, 
or  myelolymphatic,  type  is  but  rarely 
chronic,  is  usually  acute,  and  comprises 
the  special  group  of  acute  leukaemia. 

Symptoms. — Symptoms  of  Chronic 
Leukaemia. — The  onset  of  chronic  leu- 
kaemia is  usually  gradual.  The  symp- 
toms are  best  summarized  by  systems. 

The  skin  may  rarely  appear  normal  in 
color;  in  some  cases  it  is  very  white;  in 
most  cases  it  is  of  a  dull-yellow  hue. 
Petechiae,  accidental  eruptions,  and 
areas  of  pigmentation  or  of  loss  of  pig- 
ment are  common.  There  is  a  sudoral 
type.  Pruritus  and  paraesthesiae  are  often 
noted.  (Edema  may  occur,  of  four 
types:  cardiac,  anaemic,  due  to  venous 
compression,  and  the  peculiar  form  due 
to  obstruction  of  the  lymphatic  chan- 
nels. 

Stomatitis  and  tonsillitis  are  very 
common,  and  may  pass  to  ulceration, 
from  whence  haemorrhage  is  apt  to  oc- 
cur. Anorexia  or  perversion  of  appe- 
tite is  seen  in  most  cases.  Vomiting  is 
frequent;  distress  after  meals,  regurgi- 
tations, and  eructations  are  almost  con- 
stant. Diarrhoea  is  seen  oftener  than 
constipation,   and   in   the   cases  with 

4- 


SYMPTOMS.  369 

ulceration  is  persistent.  Haemorrhoids 
are  not  uncommon.  Abdominal  tender- 
ness is  often  noted.  The  enlargement  of 
the  liver  can  be  usually  demonstrated; 
it  is  hard  and  smooth  and  may  be  ten- 
der. Ascites  is  uncommon.  Jaundice 
is  sometimes  seen. 

Eapid  cardiac  action  is  the  rule.  The 
pulse  is  full  and  of  low  tension;  the 
capillary  pulse  is  often  present.  The 
heart  is  rarely  enlarged,  but  may  be  dis- 
placed by  the  spleen,  liver,  or  medias- 
tinal gland.  The  first  sound  often  lacks 
the  full  muscular  note.  Systolic  haemic 
murmurs  are  common  at  the  base  and  at 
the  apex,  while  the  venous  hum  in  the 
neck  is  still  more  frequent. 

Case  of  leukaemia  acutissima  compli- 
cated with  ulcerative  endocarditis  of  the 
aortic  valves,  permitting  regurgitation. 
The  most  striking  phenomenon  in  the 
case  was  a  centripetal  venous  pulse, 
plainly  visible  in  the  veins  of  the  back  of 
the  hand,  and  disappearing  on  pressure 
upon  the  distal  portion  of  the  vein.  Sen- 
ator (Berliner  klin.  Woch.,  Jan.  27,  '90). 

Haemorrhage  into  the  skin  and  from 
the  mucosae  are  frequent,  and  may  be 
spontaneous  or  induced  by  slight  injury. 

Case  of  leukaemia  in  which  hgematoma 
suddenly  developed  in  the  right  axilla, 
and  extended  downward  to  the  sixth  rib 
and  from  the  nipple  to  the  vertebral 
groove.  Hale  White  (Lancet,  June  9, 
'88). 

Case  of  leukaemia  in  which  there  M  as 
haemorrhage  from  the  bowels,  as  well  as 
gingival  haemorrhage  from  the  neighbor- 
hood of  a  carious  tooth.  Potain  (Gaz. 
des  Hop.,  May  17,  '88). 

Case  of  leukaemia  in  which  fatal 
haemorrhage  from  the  bladder  followed 
the  passage  of  a  catheter.  Sheawin 
(Australasian  Med.  Gaz.,  Oct.,  '88). 

Case  of  acute  leukaemia  in  which  there 
was  an  attack  of  haemoglobinaemia, 
haemoglobinuria,  and  icterus,  with  fever 
and  gastric  disorders.  The  patient  slowly 
recovered,  but,  after  several  months,  suc- 
cumbed in  a  second  attack.  Englehardt 

24 


370  LEUKEMIA. 

(St.  Petersburger  med.  Woch.,  May  2, 
'92). 

A  slight  polyuria  is  often  seen.  The 
urine  often  contains  an  excess  of  urob- 
ilin. Albumin  does  not  usually  indi- 
cate nephritis.  Albumoses  may  be 
found.  A  few  leucocytes  and  hyaline 
casts  are  often  to  be  found  in  the  sedi- 
ment. Some  cases  have  frequent  hsema- 
turia. 

A  fatal  case  of  medullary  leukaemia 
in  a  girl,  14  years  old,  the  most  striking 
post-mortem  change  being  a  diffuse 
leukaemic  infiltration  of  the  kidneys. 
Frankel  (Deut.  med.-Zeit.,  Nov.  13,  '90). 

Priapism  is  an  occasional  symptom, 
due  to  infiltration  of  the  corpora  caver- 
nosa. Leukaemia  does  not  produce  im- 
potency.  The  menstrual  function  is 
usually  deranged,  and  there  is  a  tendency 
to  much  bleeding. 

Case  of  leukaemia  in  which  there  was 
priapism  with  cessation  of  sexual  excite- 
ment. The  autopsy  showed  that  the  cor- 
pora cavernosa  had  become  transformed 
into  homogeneous  connective  tissue. 
Kast  (Zeit.  f.  klin.  Med.,  B.  8,  H.  1,  2, 
'95). 

Dyspnoea  is  almost  constant  and  does 
not  depend  entirely  on  the  anaemia,  but 
is,  in  part,  toxic.  (Edema  of  the  glottis 
or  of  the  lungs  may  occur.  Laryngeal 
ulcerations  may  produce  grave  danger, 
as  may  mediastinal  or  cervical  pressure. 
Pleural  effusion  is  rare.  Epistaxis  is 
common. 

Literature  of  '96-'97-'9S. 

Leukaemia  changes  in  the  larynx  and 
trachea  usually  consist  of  numerous  small 
nodules  in  the  mucous  membrane  of  the 
larynx  and  respiratory  mucous  mem- 
branes, or  less  frequently  slight  diffuse 
infiltrations.  Ebstein  (Wiener  klin. 
Woch.,  s.  462,  '90). 

Case  of  leukaemic  infiltration  of  the 
larynx.  At  the  autopsy  there  was  found 
perichondritis  of  the  arytenoid  cartilage 
in  addition  to  the  leukeemic  infiltration. 
The  periosteum  in  the  right  half  of  the 


SYMPTOMS. 

larynx  was  evidently  partly  infiltrated 
by  the  leukaemic  and  partly  by  a  simple 
inflammatory  process.  In  the  left  half 
the  infiltration  was  purely  leukaemic. 
Mager  (Wiener  klin.  Woch.,  No.  26,  '96). 

Changes  in  the  larynx  and  in  the 
trachea  in  cases  of  leukaemia.  Case  of  a 
boy,  aged  13  years,  who  had  attacks  of 
severe  dyspnoea,  with  croupy  cough. 
Laryngoscopical  inspection  revealed  great 
thickening  of  the  ventricular  bands,  and 
infiltration  of  the  whole  upper  portion  of 
the  larynx.  The  child  died  with  severe 
dyspnoea,  aphonia,  and  bleeding  from  the 
mouth  and  nose.  On  post-mortem  exam- 
ination it  was  found  that  the  infiltration 
of  the  larynx  and  bands  was  due  to  a 
dense  collection  of  lymphocytes  in  the 
submucous  tissue.  The  capillaries,  also, 
were  distended  with  lymphocytes,  and 
these  cells  were  especially  abundant  in 
the  interglandular  spaces.  The  submu- 
cous tissue  in  the  trachea  was  affected  in 
the  same  way.  Otto  Barnick  (Munch, 
med.  Woch.,  Apr.  19,  '98). 

The  temperature  is  rarely  normal  for 
any  length  of  time,  a  low  irregular  fever 
being  seen  at  some  period  in  most  cases. 
Chills  rarely  occur,  but  may  be  without 
significance. 

Literature  of  W-W-'dS. 

Case  of  leukaemia  under  observation 
for  three  and  a  half  months:  there  was 
daily  rise  of  temperature  followed  by  a 
gradual  fall  during  the  whole  period. 
Von  Hajek  (Wiener  klin.  Woch.,  May  20. 
'97). 

Exophthalmos  may  be  produced  by 
post-orbital  collections.  Leukamiic  reti- 
nitis occurs  in  many  cases,  often  accom- 
panied by  retinal  hemorrhages:  it  may 
cause  no  symptoms,  or  may  produce 
amaurosis.  Dimness  of  vision  may  be 
present  without  retinal  lesions.  Tinni- 
tus aurium  and  vertigo  are  common; 
deafness  may  be  rarely  due  to  hemor- 
rhage into  the  internal  ear. 

Three  autopsies  in  which  it  was  deter- 
mined that  exudations  and  haemorrhages 


LEUKAEMIA. 

in  the  middle  and  internal  ears  were  the 
cause  of  ear  disease  in  leukaemia.  Lan- 
nois  (L'Union  Med.,  Feb.  16,  '91). 

Case  of  leukaemia  in  which  sudden 
vertiginous  attacks  simulating  Meniere's 
disease  occurred.  Subsequent  anatom- 
ical examination  disclosed  a  fibrinous 
collection  in  the  utricle  and  saccule  of  the 
vestibule,  with  here  and  there  more  de- 
cided evidences  of  haemorrhage.  Lannois 
(Lyon  Med.,  Jan.  3,  '92). 

Literature  of  '96-'97-'98. 

Aural  lesions  appeared  in  10  male  and 
5  female  patients  suffering  from  leu- 
kaemia. The  aural  affection  took  the 
form  of  more  or  less  pronounced  deafness, 
usually  tending  to  rapid  aggravation, 
and  accompanied  by  tinnitus,  and  often 
vertigo.  In  a  certain  number  of  instances 
these  symptoms  constituted  Meniere's 
triad.  The  anatomical  lesions  consisted 
in  the  accumulation  of  leucocytes,  and 
the  occurrence  of  haemorrhages  both  in 
the  medullary  spaces  of  the  petrous  bone 
and  other  parts  of  the  auditory  appara- 
tus, and  particularly  in  the  internal  ear. 
Schwabach  (Zeit.  f.  Ohren.,  '97). 

Case  of  leukaemia  presenting  a  peculiar 
affection  of  the  eyelids,  which  at  first  had 
the  aspect  of  oedema,  but  on  closer  ex- 
amination proved  to  be  small  lymphatic 
tumors  which  were  not  adherent  to  the 
skin.   Litten  (Med.  Bull.,  Mar.,  '97). 

Case  of  leukaemia  complicated  by 
haemorrhage  into  the  anterior  chamber 
of  the  right  eye.  Sorger  (Miinch.  med. 
Woch.,  Aug.  30,  '98). 

Headache,  insomnia,  neuralgic  pains, 
and  depression  are  almost  constant. 
Delirium  may  occur,  toxic  in  origin; 
coma,  when  present,  is  usually  due  to 
intracranial  tumor  or  haemorrhage.  Pe- 
ripheral neuritis  is  uncommon. 

Case  of  leukaemic  bulbar  paralysis. 
Kast  (Zcits.  f.  klin.  Med.,  B.  8,  H.  12,  '95). 

Literature  of  '96-'97-'98. 

Two  cases  of  disease  of  the  spinal  cord 
due  to  leukaemia.  In  the  first  microscop- 
ical examination  of  the  cord  revealed 
small    myelitic    foci,   or.   more  strictly 


SYMPTOMS.  371 

speaking,  foci  of  acute  or  subacute  nerve- 
degeneration,  scattered  through  the  white 
substance  from  the  upper  lumbar  region 
to  the  medulla  oblongata.  Some  of  these 
degenerated  points  were  large  enough  to 
be  seen  by  the  naked  eye,  and  all  stages 
of  degeneration  were  to  be  observed, 
from  a  simple  puffed-up  appearance  of 
the  myelin  sheath  and  swelling  of  the 
axis  cylinder  to  segmentation,  breaking 
up,  and  disappearance  of  the  nerve-fibres, 
with  compensatory  hypertrophy  of  the 
neuroglia.  Changes  in  the  vessels, 
haemorrhages,  cellular  infiltration,  and 
extravasation  of  leucocytes  were  entirely 
wanting,  and  the  gray  matter  through- 
out, together  with  the  nerve-roots,  were 
absolutely  normal. 

In  the  second  case  microscopical  ex- 
amination of  the  spinal  cord  revealed 
lesions  identical  in  character,  size,  and 
distribution  with  those  of  the  first  case, 
the  gray  matter,  nerve-roots  and  vessels 
being  intact.  Nonne  (Deutsche  Zeit.  f. 
Nerv.,  Apr.  30,  '97). 

The  spleen  in  myelogenous  leukaemia 
may  reach  to  the  pelvis  below  and  touch 
the  liver  to  the  right.  It  is  hard  and 
smooth;  it  may  pulsate,  give  a  friction- 
rub,  or,  on  auscultation,  a  bruit.  Splenic 
pain  and  distress  are  quite  constant.  In 
lymphatic  leukaemia  the  spleen  is  less 
prominent.  In  all  cases  the  enlargement 
is  subject  to  fluctuations. 

The  lymphatic  glands  are  inconstantly 
enlarged  in  myelogenous,  but  constantly 
in  lymphatic,  leukaemia.  They  are  not 
hard,  often  tender,  and  usually  painful. 
In  the  axillary,  femoral,  inguinal,  and 
sacral  regions  they  may  press  on  veins, 
causing  oedema  and  cyanosis,  and  by 
pressure  on  nerve-trunks  produce  great 
pain  and  even  paralysis.  The  cervical 
glands  especially  tend  to  enlarge,  they 
limit  the  cephalic  movements,  and  may 
press  upon  the  veins.  Enlargement  of 
the  glands  at  the  base  of  the  tongue  and 
of  the  tonsils  may  produce  dysphagia. 
Enlargement  of  the  thoracic  glands  may 
produce  aphonia,  bronchial  or  tracheal 


372  LEUKEMIA. 

stenosis,  pressure  on  the  superior  vena 
cava  or  its  bronchus,  tachycardia,  dys- 
phagia, and  cardiac  dislocation.   On  per- 
cussion the  area  of  dullness  is  usually 
easily  demonstrable,  and  an  actual  pro- 
trusion of  the  mass  is  occasionally  ob- 
served.   Enlargement  of  the  retroperi- 
toneal glands  may  produce  a  large  retro- 
peritoneal tumor,  with  dislocation  of  the 
viscera,  and  perhaps  oedema  of  the  legs. 
Method   suggested  to  determine  en- 
largement of  the  thoracic  glands:  The 
patient  is  placed  before  the  observer,  the 
fingers  thrust  behind  the  sternum,  and 
then  the  patient's  head  rotated.    In  this 
way  the  thoracic  glands  may  occasion- 
ally be  felt.    Enlarged  bronchial  glands 
sometimes  push  the  arch  of  the  aorta  up 
and  make  it  palpable  behind  the  sternum. 
There  may  be,  in  addition,  a  systolic 
murmur   from   pressure   on   the  aorta. 
Enlarged  tonsils  and  lymphoid  masses  on 
the  back  of  the  tongue  may  be  observed 
and  intestinal  involvement  is  proclaimed 
by  intractable  diarrhoea.    Jaccoud  (La 
Sem.  Med.,  Mar.  11,  '91). 

Twenty-eight  cases  of  leukaemia  ana- 
lyzed: In  12  cases  the  blood  was  of  Vir- 
chow's  lienal  type,  in  4  of  lymphatic,  and 
in  12  of  mixed  type.  The  spleen  was  en- 
larged in  all,  the  liver  considerably  so  in 
10,  and  in  10  there  was  polyadenitis.  In 
4  the  mesenteric  glands  only  were  en- 
larged, in  4  the  cervical  and  thymus,  in 
2  the  mammary,  and  in  2  the  axillary 
glands.  Four  cases  occurred  in  the  first 
year  of  life  and  3  in  the  seventh  decade. 
Weber  (St.  Petersburger  med.  Woch., 
Feb.  12,  '92). 

Pain  in  and  tenderness  over  the  bones 
exists  in  some  cases  of  myelogenous  leu- 
kaemia.   Its  absence  signifies  nothing. 

Symptoms  of  Acute  Leukaemia. — 
Acute  leukaemia  presents  the  picture  of 
an  acute  infection.  There  is  an  irregular 
fever,  often  high,  and  chills  are  frequent. 
Some  of  the  lymphatic  glands  become 
acutely  enlarged,  but  this  often  subsides; 
the  spleen  is  only  moderately  enlarged. 
Haemorrhages  are  marked  symptoms, 
from  the  gums,  nostrils,  from  the  stom- 


SYMPTOMS. 

ach  and  rectum,  and  into  the  skin;  they 
persist  for  days,  and  produce  a  distinct- 
ive picture.  Ulcerations  in  the  mouth 
are  almost  constant,  and  there  is  often 
a  peculiar  foetor  to  the  breath.  Diar- 
rhoea may  be  present,  and  intestinal 
ulceration  is  common.  Vomiting  is  fre- 
quently noted.  The  pulse  is  usually  very 
rapid,  and  dyspnoea  is  marked. 

Case  of  acute  leukaemia  in  a  child  of 
10  years,  in  which,  after  a  few  days  of 
malaise,  hematuria,  purpura,  epistaxis, 
enlargement  of  the  spleen,  and,  finally, 
hemiplegia  rapidly  ensued,  and  led  to  a 
fatal  termination  in  four  and  a  half  days. 
The  ratio  of  white  to  red  corpuscles  was 
1  to  1 At  autopsy  the  spleen  and 
thymus  were  enlarged  and  various  pur- 
puric lesions  were  discovered.  Guttmann 
(Berliner  klin.  Woch.,  Nov.  29,  '91). 

Case  of  acute  leukaemia  in  a  lad  of  8 
years.  The  clinical  picture  was  that  of 
purpura  haemorrhagica,  and  post-mortem 
there  was  found  a  pure  lineal  form  of 
leukaemia.  The  duration  was  fourteen 
days.  Twenty-seven  cases  of  acute  leu- 
kaemia collected.  Eichhorst  (Virchow's 
Archiv,  B.  130,  H.  3,  '93). 

Case  of  leukaemia  associated  with 
rickets  in  a  child  1  year  old,  with  glandu- 
lar enlargement,  swelling  of  the  spleen 
and  liver,  and  purpura.  The  blood-count 
showed  2,900.000  red  corpuscles  and 
48,000  leucocytes.  There  were  numerous 
nucleated  red  corpuscles  and  poikilocytes. 
Karyokinesis  was  noted  in  some  red  cor- 
puscles. Morse  (Boston  Med.  and  Surg. 
Jour.,  Aug.  9,  '94). 

Literature  of  '96-'97-'98. 

A  characteristic  of  acute  leukaemia  is 
the  haemorrhagic  diathesis  which  is  asso- 
ciated with  swelling  of  the  glands,  spleen, 
and  liver,  and  with  peculiar  blood- 
changes.  Twelve  cases  personally  seen 
in  seven  years.  Many  cases  were  mis- 
taken for  purpura  haemorrhagica  until 
the  blood-examination  revealed  their  true 
nature.  Typical  heteroplastic  leukaemic 
growths  occur  in  the  liver  and  spleen. 
The  blood-changes  are  entirely  character- 
istic. There  is  a  remarkable  increase  of 
the  mononuclear  elements,  which  are  of 


LEUKEMIA.    PROGNOSIS.  DIAGNOSIS. 


373 


the  most  varying  sizes,  but  do  not  con- 
tain neutrophilic  granules.  A.  Fraenkel 
(Deutsche  med.  Woch.,  July  1,  '97). 

A  low  delirium  develops  in  most 
cases,  passes  into  coma,  and  death  occurs 
in  from  a  few  days  to  six  weeks.  No 
disease  could  possibly  look  more  toxic. 

Case  in  which  epistaxis  was  the  cause 
of  death.  Knipp  (Maryland  Med.  Jour., 
Nov.  17,  '88). 

Minute  haemorrhages  into  the  brain- 
substance  were  the  cause  of  death  in  a 
case  of  leukaemia.  Virchow  (Deut.  med.- 
Zeit,  Jan.  30,  '88). 

Case  of  acute  leukaemia  in  which  the 
fatal  event  was  precipitated  by  a  punct- 
ure of  the  spleen,  which  was  made 
for  diagnostic  purposes.  A.  Westphal 
(Miinchener  med.  Woch.,  Jan.  7,  '90). 

Prognosis. — As  just  stated,  the  dura- 
tion of  acute  leukaemia  is  from  a  few 
days  to  six  weeks.  The  duration  of 
chronic  leiikcemia  varies  from  one  to  four 
years,  though  longer  cases  have  been 
recorded.  Death  may  be  directly  due  to 
some  of  the  symptoms,  to  exhaustion,  or 
to  intercurrent  disease. 

Case  of  acute  leukaemia  following  in- 
fluenza, which  terminated'  in  three  days. 
Litten  (Miinchener  med.  Woch.,  Apr.  26, 
'92). 

Literature  of  '96-'97-'98. 

In  cases  of  leukaemia  complicated  by 
various  septic  processes,  considerable  im- 
provement, at  least  in  the  leucocytosis, 
occurs  as  the  infection  develops.  Marisch- 
ler  (Wien.  klin.  Woch.,  July  23,  '96). 

The  prognosis  as  to  life  in  leukaemia  is 
hopeless;  certain  cases  manifest  remis- 
sions, but  ultimately  go  on  to  a  fatal 
issue.  M.  L.  Goodkind  (P.  and  S.  Plexus, 
Apr.,  '98). 

Case  of  acute  leukaemia  in  a  child  3 
years  old  ending  fatally  thirteen  days 
after  the  onset  of  illness.  J.  L.  Morse 
(Arch,  of  Pediatrics,  May,  '98). 

Diagnosis. — Chronic  leukaemia  in  the 
active  stage  can  always  be  diagnosed  by 
a  careful  examination  of  the  blood.  In 


periods  of  quiescence  of  the  disease,  how- 
ever, the  blood  may,  for  a  time,  not  pre- 
sent the  characteristic  signs.  It  is  the 
quality,  rather  than  the  quantity,  of  the 
leucocytes  which  characterizes  leukaemia, 
though  nearly  all  cases  present  a  number 
of  leucocytes  never  seen  in  the  known 
forms  of  simple  leucocytosis.  In  very 
rare  instances  the  diagnosis  from  pseudo- 
leukemia and  sarcoma  may  be  impos- 
sible. In  children  with  secondary  anae- 
mia?, enlarged  spleens,  marked  oligocy- 
themia, pronounced  leucocytosis,  and 
some  myelocythaemia,  the  diagnosis  from 
leukaemia  presents  at  times  great  diffi- 
culties. Acute  leukaemia  resembles  the 
purpurae  on  violent  type,  and  the  blood 
of  all  purpuric  patients  should  be  ex- 
amined for  leukaemia. 

In  acute  leukaemia  anatomical  lesions 
may  antedate  the  changes  in  the  blood 
by  a  considerable  time.  Kast  (Deut. 
med.  Woch.,  Oct.  29,  '91). 

The  varied  character  of  the  leucocytes 
regarded  as  of  the  greatest  importance  in 
distinguishing  between  leucocytosis  and 
leukaemia.  The  myelocyte  of  Ehrlich 
may  be  a  valuable  diagnostic  feature,  but 
one  which  is  frequently  wanting.  Troje 
(Deutsche  med.  Woch.,  Apr.  21,  '94). 

Blood  of  two  cases  of  acute  leukaemia 
examined.  At  a  period  of  temporary  im- 
provement in  one  of  the  cases  an  ordi- 
nary examination  of  the  blood  would 
have  failed  to  discover  any  leukaemia; 
whereas  by  Ehrlich's  methods,  the  appre- 
ciable percentage  of  typical  myelocytes 
found  would  at  once  arouse  suspicion, 
even  in  the  absence  of  leucocytosis. 
Thayer  (Johns  Hopkins  Hosp.  Bull.,  May, 
June,  '91). 

Literature  of  '96-'97-'98-'99. 

Case  of  leukaemia  in  which  the  impli- 
cation of  the  lymph-glands  occurred  with, 
what  is  usually  considered,  a  typical 
myelosplenic  blood-condition.  It  seems, 
therefore,  that  the  blood-examination 
does  not  suffice  in  distinguish  the  types. 
Mussor  and  Sailer  (Trans.  Assoc.  Amer. 
Physicians,  '90) . 


374  LEUKAEMIA. 

Case  of  lymphatic  leukaemia  in  which 
the  lymphocytes  were  found  to  contain 
sharply  -  circumscribed  colorless  bodies 
which  showed  amoeboid  movements  even 
when  cold.  They  were  believed  to  be 
protozoa.  Mannaberg  (Centralb.  f.  innere 
Med.,  Apr.  25,  '96). 

There  are  only  two  forms  of  leukaemia  : 
(a)  Lymphaemia;  the  blood  shows  an  in- 
crease of  white  cells  of  the  type  of  lym- 
phocytes. (&)  Leukaemia  proper;  the 
blood  presents  an  increase  of  white  cells 
of  the  type  of  leucocytes  in  the  wider 
sense — cells  presenting  all  possible  vari- 
ations between  the  size  of  the  nucleus  and 
the  size  of  the  cell-body.  The  increase  of 
the  eosinophile-cells  occurs  generally  only 
in  leukaemia  proper,  exceptionally  in  lym- 
phaemia. The  characteristic  feature  of 
the  leukaemic  blood  as  against  that  in 
leucocytosis  is  the  polymorphism  of 
the  white  cells.  Weiss  (Hiimatologische 
Untersuchungen,  Vienna,  '96). 

Acute  leukaemia  may  be  diagnosed  by 
the  occurrence  of  a  rapidly-increasing 
anaemia,  with  its  accompanying  symp- 
toms, petechia?  over  the  body,  or  haemor- 
rhages from  the  mucous  membranes, 
with  enlargement  of  the  lymph-glands, 
fever,  and  a  moderately  enlarged  spleen 
and  liver,  accompanied  by  a  decrease  in 
the  blood  of  the  red  cells  and  an  increase 
of  the  white  cells  of  mononuclear  form. 
M.  H.  Fussell  and  A.  E.  Taylor  (Phila. 
Med.  Jour.,  Jan.  7,  ;99). 

Etiology. — The  etiology  of  the  disease 
is  probably  concerned  with  a  micro-or- 
ganismal  infection,  the  nature  of  which 
has  not  been  determined;  nor  has  the 
portal  of  infection  been  made  out.  For 
the  numerous  parasites  of  which  a  causal 
relation  to  Leukaemia  lias  been  postulated 
no  convincing  pathogenicity  has  been 
demonstrate*  1 :  they  have,  in  all  in- 
stances, been  examples  of  accidental  or 
terminal  infection.  The  morbid  changes 
and  the  symptoms  almost  indubitably 
suggest  an  infection. 

The  conditions  which  influence  the 
prevalence  of  the  disease  are  obscure. 


ETIOLOGY. 

Two-thirds  of  the  cases  are  in  males. 
The  majority  of  cases  occur  after  puberty 
and  before  the  age  of  fifty.  Cases  have 
been  seen  in  the  very  old,  however,  and 
in  infants  and  even  in  the  foetus. 

Intra-uterine  transmission  of  leukaemia 
from  mother  to  child  does  not  exist;  but 
it  still  remains  an  open  question  whether 
or  not  an  hereditary  predisposition  may 
be  transmitted  which  may  lead  to  the 
subsequent  development  of  the  disease. 
Saenger  (Gaillard's  Med.  Jour.,  Sept., 
'90). 

Literature  of  '96-'97-'98. 

Report  of  a  case  of  pronounced  leu- 
kaemia in  an  infant  born  of  healthy 
parents,  without  syphilitic  antecedents. 
On  account  of  the  verrucous  endocarditis 
found  at  the  necropsy,  the  nineteenth 
day  after  birth,  the  origin  of  the  leu- 
kaemia ascribed  to  some  infective  process 
which  affected  the  mother  during  her 
pregnancy,  but  which  remained  latent  as 
far  as  she  was  concerned.  Pollmann 
(Munch,  med.  Woch.,  Xo.  2,  '98). 

Case  of  oedema  of  the  placenta  and 
foetal  leukaemia.  Siefart  (Monats.  f. 
Geburtsh.  u.  Gyniik.,  B.  8,  H.  3,  '98). 

From  different  sources  stress  has  been 
laid  upon  the  possible  predisposing  in- 
fluence of  the  infections,  especially  ma- 
laria, of  pregnancy  and  lactation,  of 
traumatism,  and,  in  children,  of  rickets 
and  syphilis. 

Study  of  000  cases  of  leukaemia  sug- 
gesting that  factors  so  far  indicated  in 
reality  are  but  predisposing  causes,  the 
origin  of  disease  being  in  the  digestive 
tract, — i.e.,  an  autointoxication  by  toxic 
albuminoids.  Yehsemeyer  (Inter,  klin. 
Rund.,  Nov.  25,  '94). 

Case  of  leukaemia  following  a  blow  in 
the  abdomen,  (  burton  (Brit.  Med.  Jour., 
Nov.  2,  '95). 

Case  of  leukaemia  in  a  Bailor  of  42 
years,  in  which  the  disease  followed  im- 
mediately after  a  severe  abdominal  con- 
tusion.    (Oanzini    i  Hi  forma   Med.,  Xos. 

55,  56,  '95). 


LEUKAEMIA. 
Literature  of  '96-'97-'98. 

Autointoxication,  particularly  a  tox- 
aemia from  the  intestinal  tract,  occurring 
in  neuropathic  subjects  affords  favorable 
conditions  for  the  development  of  leu- 
kaemia. *M.  L.  Goodkind  (P.  and  S. 
Plexus,  Apr.,  '98). 

Several  cases  have  occurred  in  a 
family.  There  has  been  one  published 
case  which  was  apparently  acquired  by 
contagion.  In  a  few  instances  perni- 
cious anaemia  and  pseudoleuksemia  have 
seemed  to  terminate  in  true  leukaemia. 

Pathology.  —  There  are  three  main 
theories  which  aim  to  account  for  the 
lesions  of  leukaemia.  Of  the  two  earlier 
views,  the  Virchow-Neumann  theory 
considered  the  excess  of  white  corpus- 
cles due  to  an  abnormal  hyperplasia  of 
the  haematopoietic  tissues,  and  most  of 
the  adherents  of  this  view  have  conceived 
this  hyperplasia  as  analogous  to  that 
seen  in  malignant  neoplasms. 

The  evidence  points  strongly  to  the 
correctness  of  Virchow's  theory  that  leu- 
kaemia is  a  disease  primarily  of  the  blood- 
making  organs,  and  that  the  increase  of 
leucocytes  takes  place  in  these  organs. 
The  marrow-cells,  or  myelocytes,  believed 
to  be  identical  with  the  cells  of  the  mar- 
row, and  not  ordinary  leucocytes  in- 
creased in  size  by  hyperplasia ;  strong 
belief  shown  in  their  value  as  elements 
indicative  of  a  myelaemic  form  of  leu- 
kaemia, though  not  absolutely  diagnostic. 
H.  F.  Miiller  (Centralb.  f.  allg.  Path.  u. 
path.  Anat.,  Nos.  13,  14,  '94). 

The  Bilsiadecki-Lowit  theory  predi- 
cates a  retardation  in  the  evolution  and 
prolongation  of  the  life  of  the  circulat- 
ing leucocytes,  the  collections  in  the  tis- 
sues being  interpreted  as  the  results  of 
the  deposition  of  the  excess  of  the  cir- 
culating leucocytes.  Of  these  two  the 
first  undoubtedly  contains  the  primary 
truth, — that  there  is  a  marked  hyper- 
plasia of  some  or  of  all  the  resident  lym- 
phatic i issues  of  the  body,  and  that  the 


PATHOLOGY.  375 

circulatory  conditions  are  dependent 
thereon.  In  recent  years  the  neoplasmic 
conception  has  lost  its  hold  upon  investi- 
gators, who  have  gradually  evolved  the 
third  theory:  that  leukaemia  is  an  infec- 
tion, and  that  the  hyperplasia  of  the  lym- 
phatic tissues  and  the  circulatory  excess 
of  white  cells  is  the  result  of  a  specific 
stimulation  and  leucocytosis,  analogous 
to  those  seen  in  the  course  of  other  in- 
fections. Our  present  knowledge  of  leu- 
kaemia, of  the  infections  and  the  tissue- 
reactions  to  them,  and  of  the  leucocytoses 
strongly  support  this  view.  The  primary 
lesions  in  leukaemia  must  be  carefully 
separated  from  the  secondary  alterations. 

Leukaemia  believed  to  be  a  specific  in- 
fectious disease.  Westphal  (Berliner 
klin.  Woch.,  Oct.  7,  '89). 

A  priori,  the  genesis  of  leukaemia  is 
best  accounted  for  by  a  deviation  of  nu- 
trition due  to  a  lesion  of  the  great  sym- 
pathetic or  by  the  action  of  a  micro- 
organism, and  of  the  two  hypotheses  the 
parasitic  personally  preferred.  Mayet 
(Lyon  Med.,  Apr.  1,  '88). 

A  short,  blunt  bacillus  found  in  the 
spleen  of  a  person  dead  of  leukaemia.  It 
was  not  found  in  twelve  spleens  of  other 
diseases.  Fermi  (Canadian  Practitioner, 
Feb.  16,  '91). 

Leukaemia  is  due  to  a  mitotic  increase 
of  a  certain  kind  of  leucocyte  in  a  patho- 
logical manner  as  a  result  of  the  action 
of  some  cause  as  yet  unknown.  Hinden- 
burg  (Deutsches  Archiv  f.  klin.  Med.,  P>. 
54,  S.  209). 

Literature  of  '96-'97-'98. 

Case  of  acute  lymphatic  leukaemia  with 
streptococcic  infection.  Patient  first  had 
a  sharp  attack  of  sore  throat,  with  re- 
currence after  a  week,  and  then  rapid 
enlargement  of  the  glands  of  the  neck, 
axilla,  and  groin.  The  spleen  was  en- 
larged. Leukaemia  had  not  existed  prior 
to  the  throat  infection.  J.  B.  Herrick 
(N.  Y.  Med.  Rec,  July  10,  '97). 

Myelogenous  or  Leucocytic  Leu- 
kemia.— By  myelogenous  or  leucoc}rtic 


376  LEUKAEMIA. 

leukaemia  we  understand  the  type  in 
which  the  hyperplasia  affects  the  mye- 
locytes of  the  marrow  and  the  leucocytes 
derived  from  them.  It  is  the  common 
type.  The  essential  change  in  the  mar- 
row is  the  so-called  pyoid  condition,  a 
marked  overgrowth  of  the  myelocytes, 
which  more  or  less  completely  replace  the 
fatty  marrow.  Microscopically  the  tis- 
sue is  chiefly  composed  of  neutrophilic 
myelocytes,  which  in  properly  prepared 
preparations  are  seen  to  be  in  active  re- 
production and  development  into  neu- 
trophilic polymorphonuclear  leucocytes. 
The  eosinophilic  myelocytes  are  also  in 
actual  excess,  and  mast-cells  may  often 
be  seen  in  large  numbers.  The  osteo- 
plaxes  are  in  excess,  and  are  actively  en- 
gaged in  phagocytic  function  and  con- 
tain erythrocytes  and  leucocytes.  The 
lymphocytic  nodes  of  the  bone-marrow 
are  not  affected  in  the  process  of  over- 
growth. 

The  secondary  lesions  in  the  marrow 
consist,  for  the  most  part,  of  alterations 
in  the  erythrogenetic  tissues.  There  is 
a  marked  toxic  haemolysis  connected 
with  the  condition,  and  in  the  attempt 
to  keep  pace  with  the  destruction  of  the 
red  cells  the  red  marrow  undergoes  a 
compensatory  hypertrophy,  it  becomes 
splenified  like  the  foetal  marrow,  just  as 
in  pernicious  anaemia.  This  red  marrow 
may  be  universal,  or  may  appear  only  in 
scattered  areas;  in  some  cases  it  is  en- 
tirely absent.  Microscopically  the  red 
marrow  presents  myriads  of  enucleated 
red  cells  engaged  in  active  proliferation, 
the  macroblasts  being  especially  promi- 
nent. Haemorrhage  and  infarction  may 
be  present,  as  may  fatty  degeneration 
and  hyaline  changes. 

Case  of  more  or  less  pure  myelogenous 
leukaemia.  The  spleen  weighed  10 
ounces,  but  the  lymph-glands  were  not 
at  all  enlarged.  Beatty  (Dublin  Jour,  of 
Med.  Science,  May,  '91). 


PATHOLOGY. 

The  marrow-changes  are,  as  a  rule,  the 
first  and  the  essential,  though  subse- 
quently often  overshadowed  by  the 
splenic  and  lymphatic  manifestations. 
Boyd  (Practitioner,  Aug.,  '94). 

The  myelocytes  are  identical  with  mar- 
row-cells, and  are  present  in  increased 
amount  because  of  some  abnormal  ac- 
tivity in  cellular  proliferation  in  the  mar- 
row. Stanley  (Birmingham  Med.  Re- 
view, Jan.,  '94). 

Case  of  myelogenic  leukaemia  in  which 
erythrocytes  presented  numerous  mitoses. 
Pick  (Berliner  klin.  Woch.,  No.  43,  '94). 

In  acute  leukaemia  there  are  karyo- 
kinetic  changes  in  leucocytes,  besides 
great  number  of  them.  Marrow  of  long 
bones  showing  hyperplastic  multiplica- 
tion of  medullary  elements,  that  of  ribs 
containing  small  number  of  nucleated  red 
corpuscles.  Possible  indication  that 
evolution  of  young  lymph-cells  into  red 
corpuscles  impeded.  Askanazy  (Vir- 
chow's  Archiv,  B.  137,  H.  1,  '95). 

The  alterations  in  the  blood  correspond 
to  those  in  the  marrow.  The  white  cells 
number  usually  from  100,000  to  600,- 
000  per  cubic  millimetre.  Neutrophilic 
myelocytes  constitute  a  large  portion  of 
the  circulating  white  cells,  sometimes 
more  than  half.  Next  in  number  are  the 
neutrophilic  polymorphonuclear  leuco- 
cytes. Mononuclear  eosinophiles  (mye- 
locytes) and  polymorphonuclear  eosino- 
philes are  in  most  cases  present  in  large 
numbers.  The  non-granulated  large 
mononuclear  cells  are  usually  in  excess. 
Mast-cells  are  seen  in  considerable  num- 
bers. Many  of  the  cells  of  all  the  enu- 
merated types  present  a  marked  polymor- 
phism in  size,  shape,  and  appearance  of 
nuclei;  and  in  the  number,  size,  and 
staining  of  the  granules  they  vary 
greatly;  this  extreme  degree  of  polymor- 
phism is  characteristic  of  leukaemia. 
Cellular  degenerations  often  affect  these 
leucocytes,  karyolysis  being  more  fre- 
quent than  karyorrhexis.  The  lympho- 
cytes are  usually  not  increased  in  mye- 
logenous leukaemia;  if  in  excess  it  is  to 


LEUKAEMIA. 

a  slight  degree,  dependent  probably  upon 
the  anaemia,  and  the  cells  do  not  present 
the  polymorphism  and  degenerations 
seen  in  the  leukemic  corpuscles.  Cell- 
division  is  rarely  to  be  seen. 

Case  of  spleno-myelogenous  leukaemia, 
not  remarkable  except  for  the  blood- 
count  at  the  first  examination.  There 
were  260,000  leucocytes,  880,000  red  cor- 
puscles, and  30  per  cent,  of  haemoglobin. 
Brannan  (Amer.  Medico-Surg.  Bull.,  May 
15,  '94). 

In  acute  leukaemia  there  is  increase  of 
leucocytes  and  eosinophile  cells.  Micro- 
organisms in  great  number  in  blood  and 
enlarged  organs.  Hintze  (Deutsches 
Archiv  f.  klin.  Med.,  B.  53,  H.  3,  4,  '95). 

Special  transparent  polynuclear  leuco- 
cytes also  found,  but  in  remarkably  in- 
creased quantities,  in  case  of  leukaemia. 
Georgierski  (Bolnitchnaja  gaz.  Botkina, 
No.  10,  '95). 

The  red  cells  are  in  all  cases  reduced, 
little  in  some,  extremely  in  others.  As 
a  general  rule,  poikilocytosis,  microcyto- 
sis,  and  macrocytosis  exist  in  degree  cor- 
responding to  the  oligocythemia.  Ery- 
throblasts  are  very  common  in  even  mild 
cases  of  leukaemia  with  little  oligocythe- 
mia; normoblasts  are  the  most  frequent 
form  noted,  but  microblasts  and  macro- 
blasts  may  appear  in  large  numbers.  All 
the  erythrocytic  alterations  seen  in  perni- 
cious anemia  may  be  seen  in  leukaemia. 
The  quantity  of  nucleated  red  cells 
seems,  in  a  measure,  due  to  the  mechan- 
ical conditions  in  the  marrow,  but  the 
mere  presence  of  them  is  not  a  leukemic 
sign,  being  simply  the  result  of  erythro- 
genetic  overactivity's  attempting  to  com- 
pensate for  the  hemolysis. 

Chemical  changes  of  leukaemic  blood 
arc  such  as  could  be  explained  by  the 
excess  of  leucocytes  and  the  decrease  of 
red  corpuscles.  Freund  and  Obermayer 
(Zeit.  f.(physiol.  Chemie,  Mar.  24,  '91). 

Attention  called  especially  to  the  pres- 
ence of  large  numbers  of  nucleated  red 
corpuscles,  and  to  free  nuclei  of  such. 


PATHOLOGY.  377 

The  latter  seemed  to  have  been  extruded 
from  the  cell.  Indistinct  evidence  of 
mitosis  was  also  a  common  feature  of 
these  nucleated  red  cells.  McWeeney 
(Dublin  Jour.  Med.  Science,  July  14,  '94) . 

Attention  called  to  the  process  of 
filamentary  budding  of  erythroblasts 
through  the  endothelial  wall  as  a  factor 
in  the  formation  of  red  blood-cells.  Ob- 
servations made  on  leukaemic  spleen. 
John  Guit6ras  (Inter.  Med.  Mag.,  Dec, 
'95). 

From  the  circulating  blood  the  white 
corpuscles  are  deposited  in  the  various 
tissues,  and  these  collections  constitute 
the  most  important  secondary  lesions  of 
the  disease.  Probably  mechanical  dep- 
osition and  emigration  both  play  a  role 
in  the  formation  of  the  collections,  and  it 
is  commonly  believed  that,  once  estab- 
lished, the  collections  can  maintain  by 
cellular  division  their  own  existence. 
The  spleen  is  the  organ  most  often  af- 
fected. Tremendous  numbers  of  the 
leukemic  cells  are  deposited  in  the 
spleen,  causing  most  remarkable  en- 
largement, as  a  result  of  which  the  cap- 
sule thickens  and  the  fibrous  trabecule 
hypertrophy;  so  that  in  the  late  stages 
the  organ  is  very  hard.  The  essential 
lymphocytic  structures  of  the  spleen 
take  no  part  in  the  process  of  prolifera- 
tion; on  the  contrary,  they  are  very 
scarce.  The  enlargement  of  the  spleen 
is  further  augmented  by  the  exercise  of 
its  functions  in  connection  with  the  he- 
molysis constantly  going  on.  It  is  clear 
that  the  spleen  is  only  secondarily  af- 
fected in  myelogenous  leukemia,  and 
the  term  "spleno-myelogenous"  leuke- 
mia, while  serving  to  emphasize  the 
splenic  symptom,  is  not  correct  patho- 
logically. 

The  liver  is  usually  very  much  en- 
larged, due  chiefly  to  the  deposition  of 
the  circulating  leukemic  cells.  It  is 
hard,  smooth,  light  in  color,  and  presents 
an  excess  of  iron-pigment.    The  leuke- 


378  LEUKJEMIA. 

mic  collections  follow  the  vascular  chan- 
nels. The  excess  of  free  haemoglobin, 
effected  by  the  haemolysis,  imposes  upon 
the  liver  an  augmentation  of  its  func- 
tions, which  doubtless  increases  its  en- 
largement. In  a  few  cases  signs  of  a  re- 
turn to  foetal  haemogenesis  have  been 
seen  in  the  liver. 

The  intestinal  tract  is  often  the  seat 
of  large  leukemic  depositions;  the  essen- 
tial lymph-nodes  of  the  submucosa,  how- 
ever, undergo  no  abnormal  proliferation. 
The  collections  not  infrequently  necrose 
and  ulcerate,  the  destruction  being  prob- 
ably due  to  a  mixed  infection  from  the 
tract. 

The  skin  may  be  the  seat  of  deposi- 
tions, which  may  ulcerate.  Some  of  the 
cases  of  cutaneous  multiple  sarcomata 
are  of  this  nature. 

The  kidneys  usually  present  some  in- 
filtrations, which  follow  the  vascular 
channels.  Of  the  other  organs  of  the 
body  the  pancreas,  adrenal  and  thyroid 
bodies,  the  heart,  the  lungs,  the  upper 
respiratory  tract  and  mouth  (where 
ulcerations  may  occur),  and  the  brain 
may  present  infiltrations  which  are  usu- 
ally slight  in  degree.  Depositions  within 
the  lymph-glands  are  not  uncommon  in 
the  mediastinum,  in  the  retroperitoneal 
glands,  and  in  the  peripheral  glands; 
pressure-effects  are  then  frequently  pro- 
duced. Infiltrations  into  the  spinal  cord 
are  very  rare. 

Haemorrhages  are  quite  frequent  in 
myelogenous  leukaemia.  They  may  be 
in  the  skin  as  petechias,  under  the  sera, 
from  the  mucosa,  and  into  organs,  espe- 
cially the  brain.  The  blood  and  tissues 
after  death  often  contain  the  well-known 
Charcot-Leyden  crystals;  in  rare  in- 
stances they  are  present  preformed  in 
the  blood. 

Charcot-Leyden  crystals  in  the  Mood 
of  a  leuksemic  both  before  and  after 


PATHOLOGY. 

death,  though  especially  after  death. 
Ord  and  Copeland  (Lancet,  May  30,  '91). 

Charcot-Leyden  crystals  found  in  fluid 
drawn  from  the  spleen  during  life. 
Westphal  (Deutsches  Archiv  f.  klin. 
Med.,  B.  47,  H.  5,  G,  '91). 

Thromboses  are  not  rare,  most  often 
in  the  veins.  Fatty  degenerations  in  the 
parenchymatous  structures  of  the  heart, 
liver,  kidneys,  pancreas,  and  in  the  ali- 
mentary epithelium  are  quite  the  rule. 
Hyaline  changes  are  often  seen  in  both 
varieties  of  muscle. 

Lymphatic  Leukemia.  —  By  lym- 
phatic or  lymphocytic  leukaemia  we  un- 
derstand the  form  of  the  disease  in  which 
the  lymphocytic  glands,  nodes,  and 
structures  undergo  the  hyperplasia.  The 
lymphocytic  structures  comprise  the 
lymph-glands  and  spleen,  the  lymph- 
nodes  of  the  bone-marrow,  the  tonsils 
and  submucous  nodes  of  the  intestine, 
the  subcutaneous  lymph-nodes,  and  the 
scattered  lymph-strands  seen  in  all  tis- 
sues, especially  in  the  lung,  liver,  and 
kidneys.  Commonly  the  hyperplasia  af- 
fects the  lymph-glands  and  the  spleen; 
in  rare  instances  it  affects  most  notably 
the  nodes  in  the  skin  (dermic  leukaemia), 
in  the  intestine  (intestinal  leukaemia),  or 
in  the  bone-marrow  (osseous  leukaemia, 
or  lymph  aemia). 

The  essential  lesions  consist  in  an  ab- 
normal hyperplasia  of  the  glands  or 
nodes,  with  the  production  of  an  excess 
of  lymphocytes.  The  glands  are  much 
enlarged,  soft  in  the  early  stages,  but 
later  hard  from  trabecular  and  capsular 
fibrosis.  Haemorrhages  may  occur  into 
them.  The  spleen  is  usually  moderately 
enlarged,  and,  as  the  changes  in  it  are 
active,  the  term  "spleno-lvmphatic''  is 
pathologically  correct.  A  case  of  lym- 
phatic leukaemia  affecting  primarily  the 
spleen  alone  has  never  been  demon- 
strated. The  ingninal,  axillary,  sub- 
clavicular, and  cervical  glands  are  the 


LEUKEMIA. 

peripheral  sites  most  often  affected.  The 
retroperitoneal  and  mediastinal  glands 
may  be  enormously  enlarged.  In  the 
intestinal  type  the  submucous  follicles 
are  much  enlarged.  In  the  dermic  form 
small  lymph-nodes  form  multiple  tumors 
beneath  the  skin.  In  both  of  these  ulcer- 
ations may  occur.  In  the  osseous  type 
the  marrow  presents  pale  areas  resem- 
bling lymph-glands  to  the  naked  eye. 
Microscopically  all  these  structures  dis- 
play active  proliferation.  The  cells  are 
polymorphous  in  type,  and  degenerations 
are  common.  The  myelocytes  are  not  in- 
volved in  the  hyperplasia,  but  as  in  any 
severe  anaemia  the  marrow  may  be  spleni- 
fied. 

The  blood  presents  a  lymphaemia  or 
lymphocytosis.  The  number  of  white 
cells  is  much  less  than  in  the  myeloge- 
nous type,  rarely  over  150,000  per  cubic 
millimetre.  The  excess  of  cells  is  com- 
posed of  lymphocytes,  large  and  small, 
polymorphous  in  appearance,  many  pre- 
senting degenerations.  The  polymor- 
phonuclear leucocytes,  the  non-granu- 
lated large  mononuclear  leucocytes,  the 
eosinophiles,  and  the  basophiles  are  pres- 
ent in  normal  or  even  subnormal  num- 
bers. Nucleated  red  cells  are  rare.  The 
alterations  in  the  number  and  quality  of 
the  reel  cells  are  much  less  than  in  mye- 
logenous leukaemia. 

The  secondary  lesions  are  less  marked 
than  in  myelogenous  leukaemia.  The 
infiltrations  are  present  in  the  liver,  kid- 
neys, pancreas,  and  to  a  small  extent  in 
the  other  tissues,  but  they  do  not  pro- 
duce the  marked  organic  enlargements 
noted  in  the  other  variety.  The  pig- 
mentary changes  are  less  marked,  corre- 
sponding to  the  lesser  degree  of  haemol- 
ysis. The  fatty  and  other  degenerations 
are  likewise  Less  marked, — as  are  the 
haemorrhages. 

Mixed  Leukemia.— By  mixed  leukos- 


PATHOLOGY.  379 

rnia  we  understand  the  extensions  of  the 
hyperplasia  to  both  the  myelogenous  and 
lymphocytic  structures,  and  it  has  been 
well  defined  as  an  "autochthonous  hy- 
perplasia of  the  lymphatic  tissues  of  the 
entire  body,7*  both  lymphocytic  and  leu- 
cocytic.  The  hyperplasia  is  more  marked 
in  the  lymphocytic  than  in  the  myelog- 
enous structures.  Nearly  all  the  cases 
are  acute  in  form. 

The  lymph-glands  are  not  markedly 
enlarged,  they  are  soft  and  often  have 
an  haemorrhagic  tinge.  Upon  section 
the  germ-centers  are  seen  in  a  state  of 
most  remarkable  proliferation:  there  are 
infiltrations  into  the  vessel-walls  and 
thus  a  direct  flooding  of  the  circulation 
with  the  mother-cells  of  the  germ-nests, 
while  the  small  lymphocytes  reach  the 
circulation  by  the  usual  channel.  The 
same  hyperplasia  of  the  distorted  germ- 
nests  is  seen  in  the  intestinal  (where 
ulcerations  are  common),  in  the  osseous 
tymph-nodes,  and  in  the  tonsils.  The 
myelocytes  are  also  engaged  in  abnormal 
proliferation,  though  less  actively  than 
are  the  lymphatic  cells.  Splenification 
of  the  marrow  is  not  a  marked  condition. 

The  blood  presents  striking  changes. 
The  leucocytosis  is  not  marked,  rarely 
over  250,000  and  often  not  over  50,000 
per  cubic  millimetre.  The  larger  ma- 
jority of  the  cells  are  lymphocytes  of 
large. size,  corresponding  to  the  prolifer- 
ating cells  of  the  germ-nests.  The  lym- 
phocytes are  very  polymorphous  in  ap- 
pearance, and  degenerations  are  com- 
monly seen.  The  polymorphonuclear, 
eosinophilic,  and  basophilic  cells  are 
seldom  increased,  the  polymorphonuclear 
cells  are  often  decreased,  and  the  eosino- 
philes may  be  almost  absent.  Myelocytes 
are  not  usually  found  in  the  circulating 
blood,  despite  the  hyperplasia  in  the 
marrow.  The  red  cells  are  more  reduced 
than  in  chronic  leukaemia.  Nucleated 


380 


LEUKAEMIA.    PATHOLOGY.  TREATMENT. 


red  cells  are  not,  however,  a  special  feat- 
ure. The  qualitative  changes  in  the  red 
cells  are  marked. 

The  secondary  depositions  in  the  tis- 
sues are  not  marked.  This  is  due  to  the 
acuteness  of  the  process.  Nevertheless, 
they  exist  in  most  of  the  organs  and  tis- 
sues. The  spleen  is  proportionately  not 
more  enlarged  than  the  lymph-glands;  it 
is  usually  very  soft.  The  depositions  in 
the  tissues  correspond  to  the  cells  in  the 
blood.  Haemorrhages  are  very  common 
into  the  glands  and  organs,  from  the 
mucosa,  into  the  skin  and  sera;  they 
are  present  in  three-fourths  of  the  cases. 
Fatty  degenerations  are  not  so  marked  as 
in  more  chronic  cases,  but  hyaline 
changes  and  areas  of  focal  necrosis  are 
common. 

The  digestion  of  most  cases  of  leukae- 
mia is  chemically  and  physiologically  de- 
fective. The  salivary  juice  seems  little 
affected.  The  gastric  juice,  however,  is 
commonly  deficient  in  HC1,  pepsin,  and 
the  curdling  ferment.  Motility  is  often 
reduced.  The  assimilation  -  of  food  by 
such  patients  is  usually  notably  below 
the  normal. 

The  urine  presents  very  important 
alterations.  In  most  cases  a  marked  in- 
crease in  uric  acid  is  found,  often  up  to 
2  to  3  grammes  per  diem.  The  alloxuric 
bodies  are  likewise  somewhat  increased. 
These  conditions  may  produce  stone. 
The  performed  and  ethereal  sulphates, 
the  neutral  sulphur,  the  phosphates,  and 
calcium  are  eliminated  in  excess  of  the 
normal.  Albumin  is  often  present,  usu- 
ally not  with  casts.  Acetone  and  dia- 
cetic  acid  may  be  present  in  periods  of 
tissue-waste,  while  pathological  urobilin 
and  haematoporphyrinuria  are  usually 
demonstrable. 

The  tissue-changes  in  leukaemia  are 
unusually  active,  the  0  input  and  C02 
output  are  above  the  normal;  there  is, 


therefore,  rather  hyperoxidation  than 
suboxidation.  The  parenchymatous  de- 
generations are  due  to  toxaemia. 

Excretion  of  uric  acid  decidedly  in- 
creased in  three  cases  of  leukaemia.  The 
proportion  between  the  quantity  of  nitro- 
gen contained  in  the  excreted  uric  acid 
and  the  total  amount  of  nitrogen  in  the 
urine  was  also  decidedly  altered.  Boh- 
land  and  Schurz  (Deutsche  med.-Zeit., 
Nov.  10,  '90). 

Literature  of  '96-'97-'98. 

In  leukaemia  in  the  cases  where  uric- 
acid  excretion  is  normal  or  diminished, 
the  alloxur  bodies  are  increased,  and  their 
amount  varies  directly  with  the  amount 
of  leucocytes.  Gumprecht  (Cent.  f.  allg. 
Path.  u.  path.  Anat.,  vol.  vii,  p.  820,  '96). 

Metabolism  in  acute  and  chronic  leu- 
kaemia studied.  Acute  cases  were  char- 
acterized by  excessive  elimination  of 
uric  acid,  great  loss  of  nitrogen,  and  large 
amounts  of  urine,  all  increasing  up  to 
death;  in  the  chronic  cases  there  was 
an  approximate  nitrogen  equilibrium, 
moderate  quantity  of  uric  acid,  no  ante- 
mortal  increase.  There  is  no  parallelism 
between  the  number  of  leucocytes  and 
quantity  of  alloxur  bodies.  Magnus- 
Levy  (Virchow's  Archiv,  B.  152,  H.  1, 
'98). 

Treatment. — Eest,  the  best  of  care  and 
hygienic  surroundings,  and  a  nutritious 
diet  are  the  general  indications.  Arsenic 
is  the  best  remedy,  and  should  be  given 
in  ascending  doses  and  for  a  long  period 
of  time.  If  it  disturbs  the  stomach  or 
provokes  diarrhoea,  it  should  be  given 
hypodermically. 

Hypodermic  injections  of  arsenic 
recommended  in  leukaemia.  Fowler's  so- 
lution is  painful,  but  a  solution  of  arsen- 
ite  of  soda  2  grains  to  the  ounce  in  doses 
of  l/„  to  l/2  grain  has  been  used  with  ex- 
cellent effect.  Rummo  (Rif.  Med.,  No. 
1894,  '94 ). 

Bone-marrow  has  been  used  with  some 
success,  and,  given  with  arsenic,  it  lias 
i  seemed  to  heighten  its  action.  . 


Rewritten.  Newly  Indexed, 
Considerably  Enlarged. 

Illustrated  with  64  Full-page  Photo- 
graphic Plates  and  86  Illustrations 
in  the  Text.  461  Royal  Octavo 
Pages.  Prices,  net,  $4.00,  Cloth ; 
$4.75,  Sheep.  DELIVERED. 


NEW,  REVISED  EDITION 

of 

A  Textbook  on 
Practical  Obstetrics. 

BY 

EGBERT  H.  GRANDIN,  M.D., 

v mycologist  to  the  Columbian  Hospital ;  Consulting  Gyni 
cologist  to  the  French  Hospital  ;  Fellow  of  the  Amer- 
ican Gynecological  Society,  of  the  New  York 
Academy  of  Meilicine,  of  the  New  York 
Obstetrical  Society,  etc. 

~Wittx    tlass    Collaboration    of  ^ 

George  W.  Jarman,  M.D.,  $ 

Gynaecologist  to  the  Cancer  Hospital;  Instructor  in  Gynte-  \j/ 
cology  in  the  Medical  Department  of  the  Columbia  Uni-  >j' 
versity  ;  Late  Obstetric  Surgeon  of  the  New  York  ?K 
Maternity  Hospital  ;  Fellow  of  the  New 
York  Obstetrical  Society,  etc. 

I 

Vt/ 

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CHE  first  edition  of  this  valuable  work  has  been  so 
highly  commended,  and  sought  after  both  by 
practicing  physicians  and  college  professors, 
that  the  author  felt  it  a  duty  he  owed  the  profession 
to  rewrite  the  hook,  including  in  this  Second  Edi- 
tion an  account  of  the  progress  that  has  been  made 
in  these  important  branches  of  the  subject— viz.  :  ob- 
stetric Surgery  and  Puerperal  State— since  the  publi- 
cation of  the  first  edition.  New  and  important  plates 
and  illustrations,  taken  from  actual  practice,  have 
been  added,  thus  making  the  book  still  more  valuable 
to  practitioners. 

The  adoption  of  the  book  as  the  text-book  on 
Obstetrics  in  a  notably  large  number  of  the  leading 
Medical  Colleges  goes  to  prove  its  value  both  to  the 
Teacher  and  the  Student.  The  subject,  handled  so 
ably  by  the  author,  is  such  an  important  one— sin* 
a  thorough  and  correct  knowledge  and  practice  of  it 
goes  far  toward  the  saving  of  life— that  too  much  can- 
not be  known  about  it,  literally  and  practically. 


WHAT  PROMINENT  TEACHERS  OF  OBSTETRICS 
THINK  OF  IT. 

"I  have  taken  great  pleasure  in  looking  through  the 
second  edition  of  Grandin  and  Jarnians  '  Practical  Obstel 
rics.'  I  think  it  will  be  enough  for  me  to  say  that  it  is  tin 
book  I  am  using  exclusively  in  my  class  work,  and  that 
several  of  the  class  waited  two  or  three  weeks  after  col- 
lege opened  in  order  to  procure  your  second  edition."— D*. 
G.  B.  Steman,  Professor  of  Ohstetrics,  Fort  Wayne  Col- 
lege of  Medicine,  Fort  Wayne,  Ind. 

"1  like  the  work  very  much  and  shall  take  occasion 
to  call  attention  to  it  in  my  classes.  The  second  edition  If 
a  great  improvement,  and  will  have  a  cordial  welcome  bj 
students  and  the  profession."— J.  U.  IUkniiilt..  A.M.. 
M.D.,  Professor  of  Principle  and  Practice  of  Ohstetrics. 
Ohio  Medical  University,  Columbus,  Ohio. 


"  I  consider  there  is  no  better  work  on  Obstetrics  ex- 
tant than  Grandin  and  Jarman's.  I  have  recommended  ir 
to  my  class,  and  shall  at  my  next  lecture  call  the  attention 
of  my  class  to  the  new  edition  and  advise  them  to  procure 
it.  I  have  recommended  it  to  many  practitioners."— W.  C. 
Day,  M.D.,  Professor  of  Obstetrics,  Barnes  Medical  Col- 
lege, St.  Louis,  Missouri. 


"It  is  one  of  the  most  practical  works  on  Practical 
Obstetrics  I  have  at  my  command,  and  I  have  several  of 
the  most  recognized  authorities,  and  am  always  glad  and 
ready  to  quote  its  teachings  to  the  class."— J.  H.  Mc- 
Carty.  M.D.,  Professor  of  Obstetrics,  Birmingham  Med- 
ical College,  Birmingham  Alabama. 


"It  is  what  it  aims  at,  a  practical  work  on  obstetrics, 
in  the  sense  that  it  is  a  working  guide.  It  is  a  book  that  is 
most  thoroughly  up-to-date,  and  by  reason  of  its  direct 
method  and  exclusion  of  many  features  that  every  ortho- 
dox text-book  is  considered  incomplete  without,  chiefly  of 
an  anatomical  and  physiological  nature,  will  have  greater 
influence  in  impressing  the  value  of  modern  methods  of 
practice.  I  have  already  recommended  it  to  a  number  of 
physicians  and  students."— Edward  A.  Ayers,  M.D., 
Professor  of  Obstetrics,  New  York  Polyclinic  Medical 
School,  New  York  City, 

"In  my  judgment  it  is  one  of  the  best  works  of  its 
kind  now  in  reach  of  the  physician,  setting  forth  the  line  of 
symptoms  to  be  considered  by  the  practitioner  and  student 
in  making  up  his  Diagnosis  of  Pregnancy  with  valuable 
treatment  during  the  period  of  gestation,  and  enabling  the 
Accoucheur  to  guard  and  protect  his  patient  against  any 
danger  that  may  arise.  It  is  beautifully  illustrated  with 
fine  plates  of  the  different  positions  and  stages  of  labor, 
giving  the  attendant  an  idea  how  they  should  conduct  a 
case  of  confinement,  therefore  facilitating  the  cause 
which  otherwise  would  be  a  long-continued  labor."— 
George  C.  Potter,  M.D.,  Professor  of  Obstetrics,  Cen- 
tral Medical  College,  St.  Joseph,  Missouri. 

*'I  consider  the  work  a  very  valuable  one,  eminently 
practical,  thoroughly  reliable,  as  evidence  of  which  I  have 
for  some  time  past  recommended  it  to  my  students."— D. 
A.  Hodgiie ad,  M.D.,  Professor  of  Obstetrics  and  Dis- 
eases of  Children,  College  of  Physicians  and  Surgeons. 
San  Francisco,  Cal. 


"I  have  received  Grandin  and  Jarman  'Practical  Ob- 
stetrics' and,  having  looked  it  over,  am  much  pleased  with 
it.  I  shall  continue  to  recommend  it  as  a  clear,  concise, 
finely  illustrated  work,  thoroughly  up  to  date."— David 
E.  P.owman,  M.D.,  Professor  of  Obstetrics,  Toledo  Med- 
ical College,  Toledo,  Ohio. 

"  'Practical  Obstetrics,'  by  Grandin  and  Jarman.  I  wish 
to  say  that,  in  some  regards,  is  the  best  I  have  ever  seen. 
I  have  spoken  favorably  of  it  before  the  class  for  several 
years."— H.  W.  Chase,  M.D.,  Professor  of  Obstetrics, 
Omaha  Medical  College,  Omaha,  Nebraska. 


'* 4  Grandin  and  Jarman's  Obstetrics'  is  recommended 
to  our  students  as  a  text-book.  I  am  well  pleased  with  the 
work  because  it  is  practical  and  because  it  represents 
American  obstetric  practice."— H.  B.  Rittkr,  M.D.,  Pro- 
fessor of  Obstetrics  and  Hygiene,  Louisville  Medical  Col- 
lege, Louisville,  Ky. 

"I  have  been  handed  your  recently  published  work  on 
'Obstetrics,'  by  Grandin  and  Jarman.  I  consider  it  one  of 
the  best  works  I  have  seen  on  the  subject  for  the  student's 
use."— B.  P.  Muse,  M.D.,  Professor  of  Obstetrics,  Mary- 
land Medical  College,  Baltimore,  Md. 


"After  a  careful  examination  of  Grandin  and  Jarman's 
'Practical  Obstetrics,'  I  find  it  to  be  accurate  in  teaching 
all  branches  of  obstetrics  it  claims  to  cover.  It  is  thor- 
oughly practical  and  up-to-date.  It  elaborates  the  portions 
that  are  either  left  out  or  cut  short  in  so  many  of  our 
standard  works.  It  is,  therefore,  a  book  that  should  be  in 
the  hands  of  every  student  and  every  practitioner.  If  they 
ever  see  the  book  they  will  be  sure  to  read  it  "— C.  B. 
KlNYOK,  M.D.,  Professor  of  Gynaecology  and  Obstetric^ 
in  Homoeopathic  Medical  College  of  University  of  Mich- 
igan, Ann  Arbor,  Michigan. 


For  sale  by  booksellers  generally,  or  -will  be  sent, 
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118-99 


LEUKEMIA. 

Literature  of  '96-'97-'98. 

Case  of  splenic  myelogenous  leukaemia 
made  worse  by  bone-marrow.  C.  E.  Nam- 
mack  (Med.  Rec.,  Jan.  4,  '96). 

Extract  of  spleen  is  of  no  value.  Iron 
is  of  value  in  the  periods  of  apparent 
convalescence,  but  has  no  influence  on 
the  leukemic  progress. 

Case  of  splenic  anaemia  successfully 
treated  internally  with  small  doses  of 
perchloride  of  mercury.  E.  Mondigliano 
(La  Pediatria,  Apr.,  '93). 

Case  of  a  boy,  10  V2  years  old,  with  a 
considerably-enlarged  spleen  and  a  pro- 
portion of  one  white  to  ninety  red  cor- 
puscles. The  condition  was  cured  by 
oxygen- inhalations.  Kirnberger  (Deut. 
med.  Woch.,  No.  41,  '83). 

Two  cases  of  leukaemia  treated  by  in- 
halation of  oxygen.  One  of  which,  a  boy 
of  13,  was  cured;  and  the  other,  a  man 
of  35,  greatly  improved,  and  apparently 
on  the  way  to  recovery.  The  improve- 
ment in  each  case  dated  from  the  com- 
mencement of  the  oxygen-inhalations. 
Da  Costa  and  Hershey  (Amer.  Jour,  of 
the  Med.  Sciences,  Nov.,  '89). 

Oxygen-inhalations  employed  in  case 
of  lymphatic  leukaemia  without  success. 
The  gas  employed,  however,  was  dilute, 
being  one-third  nitrogen,  and  of  this 
mixture  28  quarts  were  inhaled  daily; 
whereas,  in  the  cases  of  Da  Costa  and 
Hershey,  the  oxygen  was  perfectly  pure 
and  given  in  much  larger  amount,  the 
maximum  dose  being  105  quarts  per 
diem.  Kahler  (Inter,  klin.  Rund.,  Aug. 
11,  '89). 

Literature  of  '96-'97-'98-'99. 

Carbonic-acid  gas  administered  to  two 
cases  of  leucocythsemia.  Oxygen  was 
administered  simultaneously  and  galva- 
nism was  applied  to  the  region  of  the 
spleen  for  five  minutes  before,  as  well  as 
during,  the  sitting.  In  both  cases,  one  in 
a  boy,  the  other  in  a  young  woman,  there 
was  perceptible  diminution  in  the  size  of 
the  spleen.  Ewart  (Brit.  Med.  Jour., 
July  23.  '98). 

All  treatment  in  acute  leuksemia  has 
thus  far  been  useless.  Every  ease  has 
progressed  to  a  fatal   terminal  ion  un- 


LICORICE.  381 

modified  by  the  various  forms  of  treat- 
ment employed.  M.  H.  Fussell  and  A.  E. 
Taylor  (Phila.  Med.  Jour.,  Jan.  7,  '99). 

Local  treatment  over  the  spleen  or  en- 
larged glands,  —  blisters,  cauterization, 
the  local  applications  of  iodine,  cold 
douches,  and  electrical  treatment  may 
alleviate  the  symptoms  to  some  extent. 
Excision  of  the  spleen  or  of  lymph- 
glands  is  contra-indicated  both  by  theory 
and  by  unfortunate  experience. 

The  various  systemic  disturbances — 
cough,  anorexia,  vomiting,  diarrhoea, 
oedema,  serous  efTusions,  headache,  in- 
somnia, and  neuralgia — demand  appro- 
priate treatment.  In  case  of  pressure 
upon  large  vascular  trunks  or  nerve- 
trunks  surgical  interference  may  be  in- 
dicated. 

Alonzo  Englebert  Taylor, 

Philadelphia. 

LICORICE.  —  Licorice,  or  liquorice 
(glycyrrhiza,  U.  S.  P.),  is  the  root  of 
Glycyrrhiza  gldba  (Leguminosce),  indige- 
nous to  Southern  Europe,  Syria,  and 
Persia,  and  cultivated  in  several  of  the 
northern  countries  of  Europe.  The 
sweetest  licorice  comes  from  Italy.  The 
root  contains  an  amorphous,  bitter-sweet 
glucoside,  glycyrrhiza;  a  crystallizable 
principle,  asparagin;  resin,  starch,  albu- 
min, liquin,  lime  and  magnesium  salts; 
and  malic,  phosphoric,  and  sulphuric 
acids.  When  glycyrrhiza  is  boiled  with 
dilute  acids  it  is  resolved  into  sugar  and 
a  bitter  brownish-yellow  substance  called 
glycyrrhetin.  Glycyrrhiza  treated  with 
ammonia  becomes  ammoniated  glycyr- 
rhiza, which  occurs  in  dark-brown  or 
brownish-red,  sweet  scales,  freely  soluble 
in  water  or  alcohol. 

Preparations  and  Doses. — Glycyrrhiza 
(licorice-root),  ad  libitum. 

Extractum  glycyrrhiza?,  15  to  60 
grains. 


382  LICORICE. 

Trochesci  ammonii  chloridi,  1  to  2 
troches. 

Trochesci  glycyrrhiza?  et  opii,  1  to  2 
troches. 

Extractum  glycyrrhizae  fluidum,  1/2  to 
2  drachms. 

Extractnm  glycyrrhizae  purum,  1/2  to 
2  drachms. 

Mistura  glycyrrhizae  composita,  2  to  6 
drachms. 

Glycyrrhizinum  ammoniatum,  5  to  15 
grains. 

Pulvis  glycyrrhizae  compositus,  1/2  to 
4  drachms. 

Therapeutics.  —  The  preparations  of 
licorice  are  mostly  used  in  affections  of 
the  air-passages  and  of  the  alimentary 
tract. 

Diseases  of  the  Kespiratory 
Tract. — In  bronchial  catarrh  a  popu- 
lar remedy  is  the  compound  mixture  of 
licorice,  or  brown  mixture,  which  con- 
tains 3  parts  of  pure  extract  of  licorice, 
12  parts  of  paregoric,  6  parts  of  wine 
of  antimony,  and  3  parts  each  of  sweet 
spirit  of  nitre,  gum  arabic,  and  sugar, 
and  70  parts  of  water. 

In  the  various  forms  of  pharyngitis 
and  laryngitis,  with  irritable  cough,  the 
troches  of  licorice  and  opium  (Wistar's 
cough-lozenges,  containing  2  grains  of 
extract  of  licorice  and  1/20  grain  of  ex- 
tract of  opium,  with  anise-oil,  gum,  and 
sugar)  are  useful  in  allaying  the  irrita- 
bility and  the  cough.  The  troches  of 
ammonium  chloride  are  similarly  used 
in  pharyngitis,  laryngitis,  and  subacute 
bronchitis. 

Constipation.  —  In  the  compound 
powder  of  licorice  we  have  a  valuable 
remedy  for  constipation.  In  contains  18 
parts  of  senna,  16  parts  of  licorice,  8 
parts  of  fennel,  8  parts  of  washed  sul- 
phur, and  50  parts  of  sugar.  It  is  largely 
used  as  a  laxative  during  pregnancy  and 


LINUM. 

after  childbirth,  and  may  be  given  to 
children,  on  account  of  its  pleasant  taste. 

Pharmaceutical  Uses.  —  Ammoni- 
ated  glycyrrhiza  is  a  useful  agent  to 
mask  the  bitter  taste  of  quinine,  being 
used  in  the  proportion  of  two  to  one. 
The  extract  is  used  to  conceal  the  taste 
of  unpleasant  remedies  and  to  increase 
the  cohesiveness  of  pills. 

Powdered  licorice-root  is  used  to  pre- 
vent pills  from  adhering  to  each  other, 
and  as  a  dusting-powder  in  pharmaceu- 
tical manipulations. 

LIDS.    See  Palpebr^e. 

LIME.    See  Calcium. 

LINUM. — Linum  (linseed  or  flaxseed) 
is  the  dried  ripe  seed  of  Linum  usitatis- 
simum,  the  common  flax:'  a  plant  of 
almost  universal  cultivation.  The  seeds 
are  oval  and  flattened,  and  have  sharp 
edges  and  somewhat  pointed  extremities. 
Externally  they  are  brown  and  shining; 
internally  they  are  yellowish  white. 
They  have  no  odor,  but  a  mucilaginous 
taste.  They  contain  a  fixed  oil,  wax, 
resin,  extractive,  tannin,  gum,  mucilage, 
albumin,  gluten,  and  salts.  The  fixed 
oil  is  found  in  the  interior  of  the  seed, 
and  when  expressed  without  the  aid  of 
heat  is  known  as  linseed-oil  (oleum  lini, 
'IT.  S.  P.).  When  ground,  the  seeds  form 
a  grayish  meal,  known  as  flaxseed-meal, 
ground  linseed,  or  linseed-meal.  When 
freely  ground  the  meal  is  rich  in  oil  and 
free  from  rancidity.  The  cake  of  linseed 
which  remains  after  the  oil  is  expivs-cd 
is  known  as  oil-cake,  and  when  ground 
is  known  as  cake-meal,  which  is  not  only 
poor  in  oil.  but  liable  to  be  rancid. 
Cake-meal  is  unfit  for  nse  in  medicine. 

Preparations  and  Doses. — Linum  (flax- 
seed). 


LINUM. 

Oleum  lini  (linseed-oil),  1/8  to  8 
drachms. 

Linimentum  calcis  (carron-oil). 
Therapeutics. — On  account  of  its  de- 
mulcent action  upon  mucous  membranes, 
flaxseed  is  used  in  the  treatment  of  bron- 
chitis, gastritis,  acute  cystitis,  and  ne- 
phritis. It  is  usually  given  in  the  form 
of  flaxseed-tea: — 

Whole  flaxseed,  3  drachms. 
Extract  of  licorice,  30  grains. 
Boiling  water,  10  ounces. 
Mix  and  stand  in  a  warm  place  for 
three  or  four  hours,  and  add  a  little 
lemon-juice,  lemon-peel,  and  sugar  to 
taste,  and  1  to  2  drachms  of  gum  arabic. 
If  cough  is  present  add  some  paregoric. 

Ground  flaxseed  mixed  with  boiling 
water  forms  the  well-known  flaxseed 
poultice.  It  should  be  spread  at  least 
half  an  inch  in  thickness  upon  muslin 
or  flannel,  the  surface  covered  with  gauze 
or  cheese-cloth,  and  applied  as  hot  as  can 
be  borne.  It  should  be  covered  with  thin 
rubber  cloth  to  retain  the  heat  and  moist- 
ure and  be  renewed  as  soon  as  it  begins 
to  cool  or  dry.  If  counter-irritant  effect 
is  desired,  the  surface  may  be  sprinkled 
with  dry  mustard  or  a  few  drops  of  tur- 
pentine. These  applications  are  useful 
in  pneumonia  or  pleurisy  (as  jacket- 
poultice),  peritonitis,  abscess,  boils,  fel- 
ons, inflamed  glands,  indolent  ulcers, 
etc.  Laudanum  is  a  valuable  addition 
to  a  poultice  in  painful  affections. 

Carron-oil  (linimentum  calcis)  is  an 
old  and  efficient  application  to  exclude 
air  from  burns.  The  addition  of  1 
drachm  of  carbolic  acid  to  the  pint  of 
carron-oil  increased  its  efficiency  and 
adds  antiseptic  action.  Linseed-oil, 
given  in  doses  of  1  to  2  ounces,  is  a  laxa- 
tive of  especial  value  when  haemorrhoids 
are  present;  it  has  been  used  as  a  nutri- 
ent by  Sherwell,  of  Brooklyn,  in  various 
cachectic  conditions. 


LITHIUM.  383 
LIPOMA.    See  Tumoes. 

LIPS.    See  Oeal  Cavity. 

LITHIUM. — Lithium  is  one  of  the 
alkali-metals,  and  is  generally  derived 
from  lipidolite,  a  native  silicate.  It  is 
also  found  in  petalite,  spodumene,  tri- 
phylline,  and  a  few  other  minerals,  and 
occurs  in  minute  quantities  in  some 
mineral  springs  (Buffalo,  Farmville 
[Va.],  and  Londonderry  [1ST.  LL]  lithia- 
waters).  The  metal  is  not  used  in  medi- 
cine. Like  other  alkali-metals,  it  unites 
with  oxygen,  forming  an  oxide,  which 
with  the  acids  forms  salts,  and  also  di- 
rectly chlorine  and  bromine,  etc.  Lith- 
ium carbonate  occurs  as  a  light,  white 
powder  with  distinct  alkaline  reaction, 
and  is  soluble  in  130  parts  of  water  and 
in  dilute  acids.  Lithium  citrate  occurs  as 
a  white,  crystalline  powder,  with  feeble 
alkaline  taste  and  almost  neutral  reac- 
tion. It  is  soluble  in  5  1/2  parts  of  water 
and  slightly  soluble  in  alcohol.  Lithium 
benzoate  occurs  as  a  light  white  powder 
or  in  shining  sweet  scales,  and  is  soluble 
in  4  parts  of  water  and  12  parts  of  alco- 
hol. Lithium  bromide  occurs  in  white 
deliquescent,  slightly-bitter  granules, 
and  is  soluble  in  water  and  alcohol. 
Lithium  salicylate  occurs  as  a  white  deli- 
quescent sweetish  powder,  is  soluble  in 
water  and  alcohol,  and  is  decomposed  by 
heat. 

It  has  been  found  advantageous  to  trit- 
urate the  carbonate  of  lithium  with 
bicarbonate  of  sodium  or  with  sugar,  in 
order  to  facilitate  its  solution  in  gaseous 
water.  Carles  (Jour,  de  Med.  de  Bor- 
deaux, p.  318,  "90). 

Preparations  and  Doses. 

1.  Carbonate  (lithii  carbonas),  3  to  15 
grains. 

Citrate   (lithii   citras),   10   to  30 
grains. 


381 


LITHIUM.    PHYSIOLOGICAL  ACTION.  THERAPEUTICS. 


Effervescent  citrate   (lithii  citras 
effervescens),  1  to  2  drachms. 
2.  Benzoate  (lithii  benzoas),  10  to  30 
grains. 

Bromide  (lithii  bromidum),  5  to  40 
grains. 

Salicylate  (lithii  salicylas),  10  to  30 
grains. 

[The  preparations  in  the  first  groups 
act  as  lithium;  those  of  the  second  group 
have  the  action  of  the  acid  or  element 
forming  them.] 

Physiological  Action. — Binet  has 
shown  that  lithium  salts  give  rise  in  ani- 
mals to  the  following  series  of  symptoms: 
Weakness,  diarrhoea,  nausea,  dyspnoea, 
fall  of  temperature,  convulsions,  and 
death.  The  latter  is  attributed  to  de- 
pression and  final  arrest  of  the  heart  in 
diastole,  coupled  with  an  inhibitory  in- 
fluence upon  the  respiratory  centres.  The 
peripheral  nervous  system  is  paralyzed 
and  muscular  excitability  is  reduced. 

The  lithium  salts  probably  have  an  im- 
portant influence  upon  metabolism. 
They  are  promptly  absorbed  and  elimi- 
nated with  the  urine,  which  is  rendered 
alkaline.  They  have  been  shown  capable 
-of  dissolving  uric  acid  and  the  urates,  and 
are  therefore  extensively  used  to  coun- 
teract the  so-called  uric-acid  diathesis. 

While  all  of  the  lithium  salts  possess 
diuretic  properties,  the  most  active  in  this 
respect  is  the  citrate,  which  has  the  fur- 
ther advantages  of  great  solubility  and 
comparative  freedom  from  disagreeable 
taste.  The  acetate  is  second  in  activity. 
Mendelsohn  (Deut.  med.  Woch.,  Oct.  10, 
'95). 

Therapeutics. — The  preparations  of 
lithium  have  held  a  high  reputation  for 
efficiency  in  the  treatment  of  the  uric- 
acid  diathesis  in  its  many  phases.  It  has 
been  claimed  that  they  can  dissolve  uric-  i 
acid  calculi  in  the  urinary  passages  or  in 
the  bladder.  Haig  has  called  our  atten- 
tion, however,  to  the  fact  that,  although 


lithia  forms  salts  with  uric  acid  in  the 
test-tube,  in  the  body  it  has  a  greater 
affinity  for  the  acid  sodium  phosphate  in 
the  blood,  and  thus  the  uric  acid  is  left 
uncombined. 

Rheumatism  and  Gout. — The  car- 
bonate, citrate,  and  salicylate  are  used  in 
the  treatment  of  rheumatoid  arthritis, 
gout,  and  subacute  and  chronic  rheuma- 
tism. The  carbonate  is  practically  in- 
soluble in  water  (1  to  130),  and  should 
be  given  in  freshly-made  pill  or  capsules. 
Citrate  may  be  given  in  solution  alone  in 
Vichy  water  or  combined  with  other 
remedies.  Lithium  citrate,  1 1/2  drachms 
dissolved  in  2  ounces  each  of  spirit  of 
Mindererus  and  syrup  of  lemon,  may  be 
given  in  dessertspoonful  doses  every  two 
or  three  hours  in  rheumatism  or  gout. 
Lithium  salicylate  is  especially  useful  in 
subacute  rheumatism,  given  in  doses  of 
10  to  20  grains  every  three  hours. 

Cystitis  and  Gravel.  —  The  lithia- 
salts  are  given  in  cystitis  and  gravel  with 
great  benefit.  When  there  is  an  increased 
secretion  of  ropy  mucus  and  the  pres- 
ence of  alkaline  urine,  lithium  benzoate 
is  to  be  preferred,  since  it  renders  the 
urine  more  acid;  when  the  urine  is  al- 
ready too  acid  the  carbonate  or  citrate  is 
better. 

Diabetes. — In  diabetes,  with  gouty 
taint,  the  use  of  lithium  carbonate  or 
citrate  in  dose  of  10  grains,  combined 
with  1/30  grain  of  sodium  arsenite  given 
three  times  daily,  is  often  followed  by 
remarkable  results.  (Hare.) 

In  4  cases  of  universal  pruritus  the 
best  results  have  been  obtained  from  the 
combined  use  of  bicarbonate  of  sodium 
and  carbonate  of  lithium,  after  all  other 
known  remedies  had  failed.  C.  Lange 
(Jour,  of  Cut.  and  Genito-Urin.  Dis.,  Oct., 
'91). 

Lithium  bromide  is  employed  for  the 
effect  of  the  bromine  it  contains.  It  may 
succeed  in  epilepsy  after  the  failure  of 


LIVER,  DISEASES  OF  THE.  CORSET-LIVER. 


385 


the  potassium  or  sodium  bromides.  Its 
hypnotic  power  is  regarded  by  Weir 
Mitchell  as  superior  to  that  of  potassium 
bromide. 

LITHOLAPAXY.    See  Ureters, 
Bladder,  and  Prostate. 

LIVER  AND  GALL-BLADDER,  DIS- 
EASES OF  THE. 

Diseases  of  the  Liver. 

Malformations. — Abnormalities  in  the 
form  of  the  liver  are  not  common.  They 
may  be  either  acquired  or  congenital. 

1.  Corset-liver. — The  constant  press- 
ure Of  the  lower  ribs  against  the  liver  as 
a  result  of  tight  lacing  or  the  wearing  of 
a  tight  waist-band  may  produce  a  deep, 
transverse  furrow  on  the  right  lobe  from 
atrophy  of  the  parenchyma.  The  furrow 
usually  corresponds  to  the  margin  of  the 
ribs,  and  may  be  so  deep  that  the  liver 
becomes  divided  into  a  large  upper  and 
a  small,  lower,  part  connected  together 
by  a  narrow  isthmus  or  band  composed 
chiefly  of  fibrous  tissue,  the  larger  blood- 
vessels, and  bile-ducts.  The  peritoneum 
in  the  groove  is  much  thickened.  The 
lower  portion  is  usually  rounded  and 
may  be  freely  movable  as  if  hinged  to 
the  upper,  and  appear  in  the  abdomen 
as  a  movable  tumor. 

Case  in  which  a  portion  of  liver  was 
partly  constricted  off,  and,  remaining  at- 
tached by  a  peduncle,  gave  rise  to  mov- 
able tumor.  Removed  with  the  gall- 
bladder; good  recovery.  Bastianelli  (II 
Policlinico,  Apr.,  '95). 

This  deformity  is  met  with  usually  in 
elderly  females.  There  are  usually  no 
symptoms  resulting  from  the  deformity; 
yet  in  some  there  is  said  to  be  a  con- 
stant sensation  of  pressure  and  weight  in 
the  hepatic  region.  In  occasional  cases, 
in  consequence  of  venous  stasis,  there  is 
a  temporary  swelling  of  the  isolated  por- 

4r 


tion  and  violent  pain  and  signs  of  irri- 
tation of  the  peritoneum. 

Tight  lacing  has  a  decided  effect  on 
lessening  the  how  of  bile.  The  free  and 
unfettered  action  of  the  diaphragm  is 
essential  to  normal  biliary  secretion  and 
effects  evacuation  of  the  bile-ducts  much 
in  the  same  way  as  succussion  of  the  liver 
which  saddle  exercise  affords.  W.  G. 
Collins  (Lancet,  Mar.  17,  '88). 

2.  Tongue-like  Lobes.  —  These  are 
probably  of  much  more  frequent  oc- 
currence, and  therefore  of  much  more 
importance,  than  the  corset-liver.  They 
are  both  of  importance  chiefly  on  account 
of  the  difficulties  they  present  in  diag- 
nosis. Eiedel  met  with  twelve  cases  of 
tongue-like  lobes  in  forty-two  operations 
for  gall-stones.  I  have  met  with  nine  in 
various  conditions.  In  two  the  mass  was 
thought  to  be  a  movable  kidney,  and  in 
one,  an  infant  with  hamiorrhagic  pan- 
creatitis, it  was  thought  that  possibly  the 
tongue-like  lobe  was  an  intussusception. 
They  are  met  with  at  all  ages,  and  are 
probably  usually  congenital  rather  than 
acquired  from  external  pressure.  The 
diagnosis  of  these  malformations  is  usu- 
ally easy  if  the  abdominal  wall  is  thin 
and  lax,  as  the  connection  of  the  mass 
with  the  liver  can  be  definitely  traced; 
but  if  the  abdominal  wrall  is  thick  from 
the  deposit  of  fat  or  its  muscles  tense  it 
is  often  impossible  to  differentiate  these 
from  other  masses  met  with  in  the  ab- 
domen. An  effort  should  be  made  to 
outline  the  mass  and  trace  its  connection 
to  the  liver.  This  is  often  impossible, 
as  the  base  may  be  deeply  furrowed  and 
a  loop  of  intestine  may  occupy  the 
groove. 

Treatment  for  these  abnormalities  is' 
rarely  called  for.  "When  the  mass  is 
troublesome  from  its  mobility,  and  is  not 
retained  by  a  suitable  bandage,  it  may 
be  removed.  Such  has  been  done  suc- 
cessfully. 
25 


386 


LIVER,  DISEASES  OF  THE.  DISPLACEMENTS. 


The  chief  interest  in  this  subject  is  [ 
in  connection  with  the  diagnosis  of  ah-  j 
dominal  tumors.  Unless  fully  alive  to 
the  great  variety,  as  to  shape  and  posi- 
tion, in  which  these  accessory  lobes  of 
the  liver  may  present  themselves,  one 
will  often  be  misled  in  the  diagnosis  of 
abdominal  tumors.  In  not  a  few  cases, 
even  with  the  utmost  care,  a  positive 
opinion  as  to  the  nature  of  these  tumors 
cannot  be  given. 

Eiedel,  who  first  drew  attention  to  the 
importance  of  these  abnormal  lobes,  be- 
lieves them  to  be  due  usually  to  press- 
ure on  the  liver,  as  in  tight  lacing,  and 
to  traction,  by  an  enlarged  gall-bladder. 
They  are  met  with  usually  in  women.  In 
nine  of  his  twelve  cases  the  gall-bladder 
was  attached  to  the  lower  part  of  the 
process. 

So  far  as  can  be  inferred  from  the  nine 
cases  which  I  have  met,  tight  lacing  has 
little  to  do  with  the  production  of  the 
deformity,  and  the  position  of  the  gall- 
bladder at  the  lower  part  of  the  mass 
is  an  accident  rather  than  a  cause  of  its 
formation.  In  many,  if  not  almost  all, 
cases  the  formation  of  these  lobes  seems 
to  be  developmental,  having  nothing  to 
do  with  either  pressure  or  traction. 

Displacements. 

Displacements  of  the  liver  may  be 
either  congenital  or  acquired.  As  in- 
stances of  the  former  are  hernia  of 
the  liver  through  the  diaphragm  and 
through  the  anterior  abdominal  wall. 
Interesting  examples  are  also  afforded  by 
transposition  of  viscera,  the  liver  being 
found  to  the  left  and  the  spleen  to  the 
right.  As  a  rule,  the  other  organs,  both 
of  the  thorax  and  abdomen,  are  also 
transposed,  the  cardiac  impulse  being  in 
the  fourth  or  fifth  intercostal  space  to 
the  right:  but  the  liver  and  spleen  may 
be  the  only  organs  abnormally  placed. 

Symptoms. — There  may  be  none,  the  | 


|  condition  being  discovered  accidentally. 
J  On  the  other  hand,  they  may  be  severe, 
consisting  of  pain,  tension,  and  dragging 
sensation  in  the  normal  hepatic  region. 
Jaundice,  sometimes  severe,  has  been 
present  in  a  few  cases,  probably  due  to 
tension  or  kinking  of  the  common  bile- 
duct.     Hypochondriasis  is  apt  to  de- 
velop.   The  diagnosis  may  be  difficult. 
Other  masses — as  carcinoma  of  the  omen- 
tum, tumors  of  the  right  kidney,  etc. — 
have  been  supposed  to  be  movable  liver. 
Of  the  greatest  diagnostic  importance  are 
the  form  of  the  tumor,  its  mobility,  the 
possibility  of  reducing  it  to  its  normal 
position,  the  tympanitic  note  obtainable 
over  the  normal  hepatic  region  before 
such  reduction,  and  the  dull  note  later. 
Case  in  which  diagnosis  of  tumor  of 
large  intestine,  with  atrophic  cirrhosis, 
was  made.     Laparotomy  showed  liver 
entirely  prolapsed  and  suspensory  liga- 
ment entirely  destroyed.    Convex  surface 
freshened  and  sutured  in  contact  with 
parietal  peritoneum.   Two  years  and  nine 
months  later  patient  seen.   Liver  fixed  to 
abdominal  wall  by  extensive  adhesions. 
Lanelongue  and  Faguet  (La  Sem.  M6d., 
Aug.  7,  '95). 

Literature  of  '96-'97-'98. 

Floating  liver  and  distended  gall- 
bladder mistaken  for  a  floating  kidney. 
W.  W.  Keen  (Trans.  Coll.  of  Phys..  Third 
Series,  xviii,  p.  242,  Jan.-Dec,  "90). 

Etiology.  —  Acquired  displacements 
may  be  due  to  pressure  upward  by  as- 
citic effusion,  abdominal  tumors,  and 
flatulent  distension,  and  downward  by 
thoracic  or  subdiaphragmatic  accumula- 
tions. These  are,  however,  scarcely  en- 
titled to  be  included  among  liver-dis- 
placements. The  movable  or  wandering 
liver  is  of  more  interst.  The  condition 
is  not  very  rare. 

Graham,  in  the  Transactions  of  the 
Association  of  American  Flivsicians,  vol- 
ume x,  has  tabulated  sixty-six  cases,  all 


LIVER,  DISEASES  OF  THE.    ACTIVE  CONGESTION. 


387 


of  which  have  been  reported  during  the 
last  thirty  years.  It  is  found  chiefly 
in  females  who  have  borne  several  chil- 
dren. The  displacement  is  favored  by  a 
lax  abdomen,  tight  lacing  of  the  lower 
part  of  the  chest,  and  sudden  muscular 
strain.  To  render  these  causes  effective 
it  is  probably  necessary  that  the  liga- 
ments supporting  the  liver  be  abnormally 
long  or  weak:  a  condition  that  is  doubt- 
less congenital. 

Treatment.  —  Treatment  is  not  very 
satisfactory.  A  suitable  bandage  may 
relieve  symptoms.  The  liver  cannot  be 
retained  in  the  normal  position  by  it, 
but  further  prolapse  may  be  prevented 
and  the  liver  so  far  supported  as  to  re- 
lieve the  pain  and  dragging.  In  a  few 
cases  the  liver  has  been  successfully 
sutured  in  position. 

Case  of  painful  movable  tumor  in  the 
right  iliac  fossa  which  proved  to  be  the 
displaced  liver,  adherent  to  the  abdomi- 
nal wall  by  a  thickened  portion  of  its 
capsule.  The  organ  was  pushed  up  as 
nearly  as  possible  into  its  normal  site, 
and  fastened  there  by  means  of  three 
catgut  sutures  passed  through  the  thick- 
ened capsule  and  the  deeper  layers  of  the 
abdominal  wall.  Three  months  after- 
ward the  relief  given  was  still  complete. 
Eichelot  (L'Union  Med.,  Aug.  5,  '93). 

Literature  of  '96-'97-'98. 

Case  of  fixation  of  movable  liver.  A 
Lagenbuch  incision  was  made.  The 
serous  coat  of  the  liver  and  corresponding 
surface  on  the  parietes  behind  the  costal 
cartilages  were  scratched  with  the  knife 
so  that  adhesive  exudation  might  be  en- 
couraged. Three  No.  3  silks  were  passed 
to  the  depth  of  half  an  inch  into  the  sub- 
stance of  the  liver,  and  brought  out  be- 
tween the  cartilages  of  the  false  ribs; 
finally  they  were  tied.  Three  more  silks 
were  employed  to  fix  the  liver  to  the 
upper  part  of  the  incision;  they  included 
peritoneum  and  muscle.  A  year  and  ten 
months  later  the  patient  was  in  good 
health.    Blanc  (Loire  Med..  Dec.  15.  '9Y). 


Congestion  of  the  Liver. 

This  pathological  condition  does  not 
constitute  a  disease  of  itself,  but  is 
always  associated  with  disease  elsewhere, 
especially  of  the  gastro-intestinal  tract 
and  the  heart.  The  liver  is  particularly 
prone  to  disturbance  of  its  circulation, 
because,  in  the  first  place,  of  its  large 
blood-supply  and,  in  the  second  place, 
on  account  of  its  relationship  to  the  gas- 
tro-intestinal tract  on  the  one  side  and 
to  the  heart  on  the  other.  As  the  bulk 
of  its  blood-supply  is  conveyed  to  it  by 
the  portal  vein,  it  will  share  in  all  the 
congestive  disturbances  of  the  organs 
drained  by  the  portal  system.  The  in- 
creased inflow  of  blood  resulting  from 
these  disturbances  constitutes  an  active 
congestion  of  the  liver.  On  the  other 
side  its  proximity  to  the  heart,  and  the 
absence  of  valvular  structures  between 
it  and  the  heart  render  it  very  susceptible 
to  any  obstruction  at  the  tricuspid  ori- 
fice. Such  conditions  offer  an  impedi- 
ment to  the  outflow  of  blood  from  the 
hepatic  veins,  and  results  in  passive  con- 
gestion of  the  liver. 

Active  Congestion. 

Symptoms. — They  are  those  of  gastro- 
intestinal catarrh,  such  as  headache, 
malaise,  foul  taste,  coated  tongue,  con- 
stipation, etc.  With  these  may  be  pres- 
ent a  sense  of  discomfort,  weight,  or  even 
pain  in  the  region  of  the  liver,  which 
may  also  be  tender  on  pressure.  The 
liver  may  be  felt  below  the  costal  mar- 
gin. There  may  be  slight  jaundice;  in 
the  severe  tonic  cases  the  jaundice  may 
be  intense. 

The  urine  is  dark,  of  high  specific 
gravity,  somewhat  scanty,  and  loaded 
with  urates. 

Diagnosis. — The  diagnosis  is  based  on 
tin1  association  of  the  symptoms  of  gas- 
tro-intestinal disturbance,  with  the  en- 


388 


LIVER,  DISEASES  OF  THE.    PASSIVE  CONGESTION. 


largement  of  the  liver,  with  the  discom- 
fort in  the  hepatic  region. 

Literature  of  '96-'97-'98. 

Case  in  which  marked  enlargement  of 
the  liver,  associated  with  symptoms  re- 
sembling those  of  typhoid  fever,  occurred 
in  a  young  child.  The  enlargement  began 
toward  the  close  of  the  second  week  of 
fever,  reached  its  maximum  about  the 
fourth  week,  and  then  slowly  receded.  It 
was  associated  with  no  tenderness,  no 
ascites,  no  symptoms  of  jaundice.  A.  U. 
Blackader  (Amer.  Pediatric  Society,  May 
26,  '96). 

Etiology.  —  There  are  two  main 
groups  of  causes:  (1)  gastro-intestinal 
and  (2)  toxic.  The  most  common  of  the 
first  are  catarrhal  conditions  of  the  stom- 
ach and  intestines  resulting  from  undue 
indulgence  in  food,  and  drink,  especially 
if  of  a  stimulating  nature,  as  spices  and 
alcohol.  The  habitual  use  of  spirits  to 
excess  furnishes  the  most  marked  exam- 
ples in  these  northern  climates.  Persons 
of  sedentary  habits  are  more  liable  to  be 
affected,  especially  at  middle  age.  Toxic 
causes  occur  in  infectious  diseases,  espe- 
cially in  malaria,  dysentery,  typhoid 
fever,  yellow  fever,  etc.  Even  these 
causes  act  chiefly  through  the  gastro- 
intestinal tract.  They  are  much  more 
common  in  tropical  climates. 

Active  congestion  of  the  liver  is  also 
met  with  in  suppressed  menstruation 
and  in  diabetes  mellitus.  In  both  of 
these  it  has  been  attributed  to  vasomotor 
disturbance,  but  in  diabetes  the  increased 
work  thrown  on  the  liver  may  be  the 
chief  cause. 

Morbid  Anatomy. — The  liver  is  en- 
larged, dark  in  color  and  the  vessels  full 
of  blood.  The  distension  of  the  lobule 
with  blood  is  not  limited  to  the  centre, 
but  is  general.  There  is  often  some  fatty 
change  in  the  liver-cells. 

Treatment.  —  The    indications  are 


I  chiefly  two:  (1)  to  correct  the  habits 
that  have  mainly  caused  the  condition 
and  ( 2 )  to  relieve  the  gastro-intestinal 
conditions  and  the  hyperemia  of  the 
liver.  We  aim  at  attaining  both  objects 
simultaneously.    The  diet  should  be  of 

I  the  blandest  nature.  In  severe  cases  no 
food  should  be  given  until  the  bowels 
are  acted  on  and  the.  portal  system  de- 
pleted by  a  brisk  laxative.  AVater  should 
be  taken  freely  on  an  empty  stomach. 
The  food  should  be  regulated  according 
to  the  needs  of  each  case  so  as  not  to  tax 
the  digestive  powers.  Exercise  should 
be  free,  but  without  undue  fatigue. 
Passive  Congestion  of  the  Liver. 
Definition. — Passive  congestion  of 
the  liver  (nutmeg  liver,  cardiac  liver, 
red  or  cyanotic  atrophy  of  the  liver),  is 
a  pathological  condition  caused  by  ob- 
struction to  the  outflow  of  blood  from 
the  liver. 

Symptoms. — The  symptoms  are  chiefly 
those  of  the  condition  of  the  heart  and 
lungs  causing  the  hepatic  congestion. 
There  may  be  a  sense  of  weight  and  full- 
ness in  the  right  hypochondrium,  ag- 
gravated by  external  pressure,  deep  inspi- 
ration, and  by  lying  on  the  left  side. 

Enlargement  of  the  liver  is  one  of  the 
chief  signs  and  is  usually  best  demon- 
strated by  palpation.  When  large,  the 
liver  can  often  be  delimited  by  inspec- 
tion. Percussion  is  usually  unreliable 
on  account  of  distension  of  the  intestines. 

Pulsation  of  the  liver  is  often  present 
in  severe  cases;  it  disappears  when  the 
induration  develops  and  the  heart  be- 
comes weak.  I  have  seen  it  persist  in 
cases  of  initial  stenosis  until  within  a 
few  weeks  of  death. 

Gastro-intestinal  symptoms  are  always 
present.  They  result  from  the  portal 
congestion  induced  by  the  hepatic  ob- 
struction. They  consist  in  disturbed 
digestion,  and.  often,  haemorrhoids. 


LIVER,  DISEASES  OF  THE.    PASSIVE  CONGESTION. 


389 


Ascites  is  frequent.  In  the  early  stage 
it  occurs  as  a  part  of  general  dropsy. 
Later,  when  the  liver  becomes  indurated 
it  is  increased  by  the  portal  obstruction. 
Jaundice  is  usually  present,  and  is  a 
definite  symptom  in  the  advanced  cases. 
It  is  probably  secondary  to  the  gastro- 
duodenal  catarrh.  It  is  usually  most 
marked  in  the  cardiac  cases,  and,  with 
the  cyanosis  existing  in  such  cases,  it 
causes  a  peculiar  dusky-green  tint,  of  the 
face  especially. 

Etiology. — The  causes  leading  to  this 
condition  are  such  as  lead  to  interfer- 
ence with  the  free  flow  of  blood  through 
the  heart,  and  include,  therefore,  all 
changes  in  the  heart  and  lungs  which 
tend  to  render  the  right  ventricle  in- 
competent. Of  the  cardiac  conditions 
the  most  common  is  mitral  disease,  espe- 
cially stenosis;  but  all  heart-lesions, 
whether  of  the  valves  or  of  the  sub- 
stance of  the  heart,  tend  to  impede  the 
venous  flow  by  ultimately  overtaxing  the 
right  heart.  Such  diseases  of  the  lungs 
as  emphysema,  asthma,  chronic  bron- 
chitis, etc.,  are  also  frequent  causes  of 
dilatation  of  the  right  heart,  and  thus 
lead  to  obstruction  to  the  outflow  from 
the  liver. 

Deformity  of  the  spine,  pleuritic 
effusion,  aneurism,  and  intrathoracic 
tumors  may  obstruct  the  flow  of  blood 
through  the  heart  and  lungs  or  press 
upon  the  vena  cava  directly. 

Occasionally  a  local  lesion,  as  peri- 
hepatitis, may  compress  the  hepatic  veins 
themselves  or  the  vena  cava  and  ob- 
stmcl  the  outflow  from  the  liver. 

Mown  i)  Anatomy. — In  the  early  stage 
there  is  great  engorgement  of  the  hepatic 
veins  and  their  intralobular  brandies 
and  capillaries.  The  liver  may  become 
much  enlarged,  its  lower  border  extend- 
ing in  time  to,  or  even  below,  the  um- 


bilicus.   If  the  obstruction  be  removed 
'before  organic  changes  have  occurred  in 
the  liver,  the  vessels  rapidly  empty  them- 
selves, and  the  liver  returns  to  its  nor- 
mal  size.     Even  after  long-continued 
j  congestion  the  liver  may  be  much  smaller 
|  after  death,  unless  escape  of  the  blood 
i  from  the  hepatic  veins  is  prevented  by 
distension  of  the  right  ventricle. 

Persistent  hyperemia  leads  in  time 
to  structural  changes.  As  the  intra- 
lobular veins  are  greatly  dilated,  the 
liver-cells  around  them  atrophy  from 
pressure,  and  blood-pigment  is  deposited. 
The  centre  of  the  lobule  becomes  dark, 
contrasting  strongly  with  the  periphery, 
which  becomes  yelloAvish,  on  account  of 
fatty  degeneration  of  its  cells;  hence  the 
"nutmeg"  appearance  of  the  section. 
In  course  of  time  atrophy  of  the  liver- 
1  cells  is  succeeded  by  increase  of  connect- 
ive tissue.  Induration  and  shrinking  re- 
sult, and  may  lead  to  considerable  re- 
duction in  the  size  of  the  liver. 

Teeatment. — The  treatment  is  chiefly 
that  of  the  condition  of  the  heart  or 
lungs  that  causes  it,  at  the  same  time 
endeavoring  to  relieve  portal  congestion. 
The  latter  is  usually  effected1  by  the  ac- 
tion of  cathartics.  A  more  rapid  effect 
may  be  obtained  by  local  depletion  with 
leeches,  five  or  six  being  applied  over  the 
liver.  Their  application  is  usually  at- 
tended by  marked  relief  when  there  is 
|  pain  and  distress  in  this  region. 

Calomel,  in  repeated  doses,  is  not  only 
an  active  cathartic,  but  also  an  efficient 
diuretic  in  such  cases.  Digitalis  may  be 
combined  with  it  to  increase  the  power 
of  the  heart  and  secure  greater  diuretic 
effect.  The  condition  of  the  heart  re- 
quires the  administration  of  heart-tonies. 
as  digitalis,  strychnine,  etc.  Vegetable 
cathartics  —  as  podophvllin,  colocyntb. 
;  jalap,  aloes,  etc. — may  be  used,  or  salines, 
|  such  as  sulphate  of  soda,  sulphate  of 


390 


LIVER,  DISEASES  OF  THE.  PERIHEPATITIS. 


magnesia,  or  the  natural  purgative  waters 
(such  as  Apenta  or  Hunyadi,  Rubinat, 
Hawthorn,  Friedrichshall),  etc. 
Perihepatitis. 

This  consists  in  an  inflammation  of 
the  peritoneal  capsule  of  the  liver.  In- 
flammation of  the  fibrous  capsule  apart 
from  the  peritoneal  occurs  only  as  sec- 
ondary to  interstitial  hepatitis. 

Inflammation  of  the  peritoneal  cover- 
ing of  the  liver  may  occur  either  as  a 
part  of  general  peritonitis  or  as  a  local 
disease.  It  may  be  acute  or  chronic,  the 
former  being  usually  suppurative  while 
the  latter  is  always  fibrinous  or  adhesive. 

Acute  Perihepatitis;  Subphrenic  Ab- 
scess ;  Pyopneumoperihepatitis. 

Symptoms. — The  development  of  the 
disease  may  be  with  striking  symptoms 
suggestive  of  perforative  peritonitis  of 
the  upper  part  of  the  abdomen,  or  it  may 
be  so  insidious  as  not  to  attract  atten- 
tion until  the  abscess  has  attained  a 
large  size. 

Pain  in  the  right  hypochondrium  or 
epigastrium  is  the  most  prominent  symp- 
tom. It  is  increased  by  pressure  and 
movement;  hence  the  respiration  is  i 
shallow  and  costal.  Fever,  often  ush- 
ered in  by  a  chill,  is  present;  it  may 
be  quite  remittent.  There  may  also  be 
abdominal  distension,  vomiting,  hic- 
cough, slight  jaundice,  weak  pulse,  etc. 

The  physical  signs  presented  will  de- 
pond  largely  on  the  size  of  the  abscess. 
In  the  beginning  there  may  be  a  friction- 
rub.  If  the  abscess  is  large  there  is  pre- 
sented great  fullness  in  the  right  hypo- 
chondrium, with  extension  upward  of 
hepatic  dullness,  even  to  the  angle  of 
the  scapula,  and  of  the  ed^e  of  liver 
downward,  it  may  be,  to  the  umbilicus. 
The  upper  limit  of  dullness  is  convex 
toward  the  thorax,  following  the  curve 
of  the  diaphragm.  Over  this  area  there 
is  absence  of  all  respiratory  signs.  The 


course  of  acute  perihepatitis,  in  the  ab- 
sence of  suppuration,  may  be  rapid,  re- 
covery taking  place  in  a  few  days;  in 
suppurative  cases  it  may  be  prolonged 
for  months  with  all  the  symptoms  of 
chronic  suppuration,  as  irregular  tem- 
perature, sweats,  loss  of  flesh,  etc.  In 
many  cases  fistulous  openings  take  place 
through  the  diaphragm,  causing  a  local- 
ized empyema,  which,  in  time,  perforates 
the  lung  into  a  bronchus,  with  abundant 
purulent  expectoration,  or  externally 
through  an  intercostal  space.  In  others 
the  abscess  discharges  into  the  stomach 
or  intestine.  The  general  course  of  sub- 
phrenic abscess  resembles  that  of  em- 
pyema or  abscess  of  the  liver.  The  re- 
sult is  usually  fatal,  unless  efficient 
drainage  be  established.  Of  all  the  cases 
recorded  only  about  twenty  have  recov- 
ered. 

Diagxosis.  —  In  subphrenic  abscess 
the  signs  are  so  indefinite  that  a  diag- 
nosis is  only  exceptionally  made.  The 
abscess  is  usually  mistaken  for  empyema. 
A  history  of  disease  of  the  stomach, 
duodenum,  or  gall-bladder  would  indi- 
cate a  perihepatitis,  as  would  also  a  his- 
tory of  abscess  from  appendicitis.  The 
absence  of  a  history  of  intrathoracic 
symptoms — such  as  cough,  expectora- 
tion, etc. — renders  pleuritic  disease  im- 
probable. 

The  physical  signs  are  those  of  massive 
enlargement  of  the  liver;  if  the  abscess- 
cavity  contains  air,  the  signs  of  movable 
dullness  and  tympany  of  pneumothorax 
are  added.  However,  the  bulging  of  the 
right  side  is  greatest  below  the  dia- 
phragm rather  than  above.  The  dia- 
phragm may  be  pressed  upward  to  the 
third,  or  even  the  second  rib,  but,  how- 
ever high  it  is.  its  limits  are  well  de- 
fined and  above  it  the  respiratory  sounds 
are  not  obscured.  The  lower  border  of 
the  liver  may  he  greatly  depressed.  The 


LIVER,  DISEASES  OF  THE. 


CHRONIC  PERIHEPATITIS. 


391 


heart  is  not  much  displaced,  as  it  is  in  J 
pleural  effusion. 

On  exploratory  puncture,  if  the  pus  is 
reached,  the  spurting  is  most  forcible  on 
inspiration,  owing  to  the  descent  of  the 
diaphragm.  This  would  practically  be 
cou elusive  evidence  of  the  seat  of  the 
abscess.  The  presence  of  bile-pigment 
in  the  pus  would  also  indicate  that  the 
abscess  is  below  the  diaphragm. 

Case  of  suppurative  perihepatitis  and 
abscess  of  the  liver  without  any  demon- 
strable connection  between  the  two  le- 
sions. The  pus  of  the  peritoneal  abscess 
was  sterile,  while  from  that  of  the  liver 
proper  pure  cultures  of  the  bacterium 
coli  commune  were  obtained.  Arnaud  j 
(Marseille-med.,  Apr.  15,  '93). 

Etiology.  —  It  occurs  occasionally 
from  a  blow  or  direct  injury.  It  is  usu- 
ally secondary  to  disease  in  some  adjacent 
part  or  of  the  liver  itself,  such  as  per-  j 
forating  ulcer  of  the  stomach  or  duo- 
denum, perforation  of  the  gall-bladder, 
perforation  of  the  intestine  or  the  ap- 
pendix; abscess  of,  or  in  the  region  of, 
the  kidney,  spleen,  or  appendix;  sup- 
puration in  the  right  pleura,  the  pyog- 
enic organisms  making  their  way  through 
the  diaphragm  by  the  lymphatics;  ab- 
scess of  the  liver,  echinococcus  cyst  of 
the  liver,  suppurative  cholangitis,  etc. 

.  Morbid  Anatomy. — In  the  early  stage 
the  peritoneum  of  the  liver  and  of  the. 
corresponding  part  of  the  diaphragm 
presents  the  signs  of  inflammation.  The 
inflammation  at  the  margins  of  the  af- 
fected area  being  less  severe,  adhesion 
of  the  opposing  surfaces  takes  place, 
while  the  exudate  in  the  central  part, 
being  rich  in  leucocytes,  liquefies,  and 
an  abscess  results.  The  abscess  may  be 
small  or  so  large  as  to  contain  a  quart 
or  more  of  pus.  The  pus  may  be 
creamy  and  odorless,  but  more  often  it 
is  foetid  and  contains  necrotic  tissue.  ! 
It  may  be  dark  red  from'  admixture  of  1 


blood  or  green  from  bile.  Occasionally 
air  or  gas  is  present,  even  when  no  com- 
munication with  a  bronchus  or  with  the 
stomach  or  bowel  can  be  found.  These 
abscesses  are  found  usually  between  the 
right  lobe  of  the  liver  and  the  dia- 
phragm, but  may  be  over  the  left  lobe. 

Treatment. — In  the  early  stages  the 
aim  of  treatment  should  be  to  secure  re- 
lief from  pain  and  arrest  of  the  inflam- 
mation. This  is  best  effected  by  rest  in 
bed,  the  application  of  five  or  six  leeches 
over  the  seat  of  disease,  and  the  hypo- 
dermic injection  of  morphine.  Purging 
freely  by  salines  may  be  of  much  benefit. 
Useful,  but  less  effective,  means  than 
leeching  are  the  local  application  of  heat, 
poultices,  sinapisms,  or  blisters.  As  soon 
as  the  formation  of  pus  can  be  deter- 
mined, free  drainage  should  be  resorted 
to.  This  may  necessitate  the  resection 
of  one  or  more  ribs,  but  in  any  case  the 
drainage  should  be  as  complete  as  pos- 
sible. 

Case  of  traumatic  perihepatic  abscess. 
Biological  examination  showed  nothing 
present  but  the  ordinary  pathogenic  mi- 
crobes. Recovery  after  operation  was 
very  rapid.  J.  B.  Gibbs  (X.  Y.  Med. 
Jour.,  Bee.  21,  "95). 

Literature  of  '96-'97-'98. 

Case  of  subphrenic  liver-abscess :  trans- 
pleural drainage  followed  by  pyaemia, 
and  finally  recovery.  Gerster  (Annals  of 
Surg.,  May,  '98). 

Chronic  Perihepatitis. 

This  condition  may  be  local  or  general. 
Local  perihepatitis  is  always  secondary. 
It  is  seen,  for  example,  around  the  gall- 
bladder in  some  cases  of  gall-stones;  over 
a  tumor  in  the  liver;  at  the  point  of  ad- 
hesion to  the  liver  of  an  ulcerated  stom- 
ach or  intestine;  as  the  result  of  a  local 
tuberculous  or  carcinomatous  deposit; 
and  in  manv  cases  of  venous  obstruction 


392 


LIVER,  DISEASES  OF  THE. 


ACUTE  YELLOW  ATROPHY. 


whether  from  cardiac  or  pulmonary  dis- 
ease. It  may  result  also  from  pressure, 
as  in  the  furrows  produced  by  tight  lac- 
ing or  constriction  of  the  liver  from  any 
cause. 

General  perihepatitis  is  a  very  differ- 
ent condition.  Our  knowledge  of  it  is 
derived  chiefly  from  the  records  of  Guy's 
Hospital.  In  "Allbutf  s  System  of  Med- 
icine/' volume  iv,  Dr.  W.  Hale  White 
gives  a  valuable  account  of  the  condi- 
tion based  on  these  records.  In  it  "the 
whole  capsule  becomes  thick,  opaque, 
and  white  .  .  .  easily  peels  off  the 
subjacent  liver,  the  surface  of  which  is 
smooth;  and  for  some  unexplained 
reason  it  is  quite  common  to  find  the 
inferior  edge  folded  up  on  to  the  ante- 
rior surface  of  the  liver."  This  thick- 
ened capsule  is  often  pitted  deeply.  The 
liver  is  usually  slightly  atrophied,  but 
otherwise  little  altered.  The  thickened 
capsule  does  not  seem  to  cause  pressure 
upon  the  vessels  at  the  transverse  fissure. 
The  capsule  of  the  spleen  and  the  gen- 
eral peritoneum  is  usually  also  thick- 
ened. The  omentum  may  be  thickened 
and  contracted,  forming  a  tumor  across 
the  abdomen. 

Of  the  22  cases  analyzed  by  White  in 
19  there  was  chronic  granular  kidney, 
and  he  thinks  the  chronic  peritonitis  and 
general  perihepatitis  should  be  regarded 
as  a  sequel  to  the  renal  disease.  Ascites, 
resulting  probably  from  the  chronic  peri- 
tonitis, is  nearly  always  abundant  and 
requires  repeated  tapping.  These  cases 
are  doubtless  frequently  looked  upon  as 
cirrhosis  of  the  liver.  Further  study  of 
the  condition  is  much  needed. 

Acute  Yellow  Atrophy  of  the  Liver 
(Malignant  Jaundice). 

Definition. — A  grave  form  of  jaundice 
characterized  by  extensive  destruction  of 
the  liver-cells,  with  atrophy  of  the  liver 
and  clinically  by  grave  constitutional 


disturbance  in  which  the  cerebral  symp- 
toms are  especially  prominent. 

Symptoms. — In  the  prodromal  period 
I  there  is  no  time  to  distinguish  it  from 
ordinary  jaundice.  The  same  symptoms 
usher  in  loss  of  appetite,  malaise,  nausea, 
and  vomiting,  jaundice  following  in  a 
day  or  two.  It  differs  from  ordinary 
jaundice  in  the  occurrence  of  some  rise 
of  temperature. 

Grave  infectious  icterus,  although 
usually  attended  by  hyperpyrexia,  may 
present  a  subnormal  temperature.  The 
disease  is  due  to  bacillus  coli  communis. 
Hanot  (Le  Bull.  Med..  Apr.,  '93). 

This  stage  may  last  from  a  few  days 
to  two  or  three  weeks.  The  bowels  are 
constipated  and  faeces  pale;  the  urine 
contains  bile-pigment.  There  may  be 
pain  in  the  hepatic  region. 

Suddenly  a  marked  change  occurs, 
characterized  by  severe  headache,  re- 
peated vomiting,  delirium,  and  restless- 
ness. The  vomited  matters  are  at  first 
bile-stained  and  later  contain  blood  more 
or  less  altered,  and  the  stools  may  also 
contain  blood,  making  them  dark  and 
offensive.  At  the  same  time  the  jaun- 
dice deepens  and  becomes  of  a  greenish 
hue.  The  temperature  falls  to  normal, 
or  usually  below  it;  the  pulse  rises  to 
120  or  more  and  becomes  weak.  Stupor 
sets  in  and  deepens  into  coma.  There 
may  be  convulsions.  In  women  menor- 
rhagia  may  occur  and,  if  pregnant,  abor- 
tion or  premature  delivery  take  place. 

Literature  of  '96-'97-'98. 

Case  of  acute  yellow  atrophy  in  a 
woman  who  had  passed  through  five  nor- 
mal labors  and  presented  a  high  degree 
of  jaundice  during  her  sixth  pregnancy. 
The  liver-dullness  extended  over  an  area 
only  two  or  three  fingers'  breadths  in 
extent  and  the  urine  was  covered  with 
bile,  but  otherwise  there  was  no  abnor- 
mal signs  or  symptoms.  The  patient 
sank  into  a  state  of  stupor,  gave  birth  t<> 
a  macerated  foetus,  and  died  two  days 


LIVER,  DISEASES  OF  THE. 


ACUTE  YELLOW  ATROPHY. 


393 


later.  H.  Thompson  (Centralb.  f.  Gynak., 
Nov.  12,  '98). 

The  urine  becomes  deeply  bile-stained 
and  often  contains  tube-casts.  It  be- 
comes lessened  and  may  be  suppressed. 
There  is  great  diminution,  or  even  ab- 
sence, of  urea,  and  its  place  usually  is 
taken  by  abnormal  constituents,  espe- 
cially by  tyrosin  and  leucin. 

Literature  of  '96-'97-'98. 

A  case  of  acute  yellow  atrophy  follow- 
ing syphilitic  infection.  For  the  last 
fourteen  days  of  life  daily  examinations 
were  made  of  the  urine  to  determine  the 
amount  of  urea,  ammonium,  the  alloxin 
bodies,  and  the  uric  acid  excreted.  The 
total  quantity  of  nitrogen  remained  al- 
most constant.  The  urea  was  perfectly 
normal  in  amount  until  the  last  two 
days,  when,  during  the  existence  of  severe 
coma,  there  was  a  moderate  reduction. 
The  ammonium  was  slightly  increased, 
but  hardly  enough  to  be  supposed  to  be 
the  result  of  insufficiency  of  the  hepatic 
cells  and  consequent  imperfect  formation 
of  the  urea.  Richter  (Berl.  klin.  Woch., 
No.  21,  '96). 

The  most  characteristic  physical  sign 
in  this  stage  is  the  rapid  diminution,  it 
may  be  disappearance,  of  the  area  of 
hepatic  dullness;  so  that  the  hepatic  area 
may  become  tympanitic.  It  is  also  fre- 
quently tender  to  pressure,  even  in  the 
comatose  state. 

The  stage  lasts  only  two  or  three  days 
and  nearly  always  terminates  fatally. 

Diagnosis. — It  is  not  possible  to  dis- 
tinguish acute  yellow  atrophy  before  the 
development  of  the  grave  symptoms. 
Then  the  symptom  group  is  character- 
istic: intense  jaundice;  severe,  persistent 
vomiiing,  rapid  disappearance  of  hepatic 
dullness;  delirium,  passing  rapidly  into 
coma;  leucin  and  tyrosin  crystals  in  the 
urine. 

Hypertrophic  cirrhosis  sometimes  pre- 
sents similar  symptoms,  but  the  long 


duration  and  the  large  liver  serve  to  ex- 
clude this  affection.  In  this  the  symp- 
toms of  icterus  gravis  may  develop  and 
the  case  present  all  the  features  of  acute 
yelloAV  atrophy. 

Phosphorus  poisoning  closely  resem- 
bles acute  yellow  atrophy,  but  the  liver 
does  not  diminish  so  rapidly,  if  at  all, 
the  nervous  symptoms  are  not  so  grave, 
leucin  and  tyrosin  do  not  usually  appear 
in  the  urine  in  phosphorus  poisoning, 
and  the  gastric  symptoms  are  usually 
more  severe. 

Etiology. — This  disease  is  rare.  Until 
1894  Hunter  found  but  250  cases  re- 
corded, and  since  then  (1895  to  1898, 
inclusive)  I  have  found  the  reports  of 
29  cases.  A  few  observers  have,  how- 
ever, seen  several  cases  within  a  few 
months,  indicating  an  endemic  agent, 
while  others  with  large  experience  have 
not  met  a  case.  I  met  with  one  in  1890 
in  the  Toronto  General  Hospital. 

No  age  is  exempt,  from  the  infant  of 
a  few  days  tp  the  octogenarian.  It  is 
most  common  between  the  ages  of  20 
and  30  years. 

It  is  more  common  in  females  than 
males,  especially  between  the  ages  of  20 
and  40;  that  is,  during  the  childbearing 
period.  ■  Pregnancy  has  a  most  impor- 
tant bearing  on  the  causation,  nearly 
half  the  cases  met  with  in  women  oc- 
curring during  pregnancy,  especially  the 
latter  part  of  it.  This  is  probably  ex- 
plained by  the  fact  that  some  degenera- 
tion of  the  cells  of  the  liver  and  kidney 
is  a  common  condition  in  pregnancy. 
Fear  and  mental  emotion  have  appar- 
ently been  the  cause  in  a  few  cases. 

Case  of  acute  yellow  atrophy  in  which 
the  onset  of  the  symptoms  dated  from  a 
visit  of  the  patient  to  the  scene  of  a  rail- 
road accident.  Psychic  trauma  had  much 
to  do  with  the  development  of  the  dis- 
ease. Stress  laid  upon  the  occurrence  of 
ascites  as  a  complication  of  acute  yellow 


394 


LIVER,  DISEASES  OF  THE. 


ACUTE  YELLOW  ATROPHY. 


atrophy.  Burckhardt  (Corres.-blatt  f. 
Schweizer  Aerzte,  Aug.  14,  '91). 

Alcoholic  excess  has  preceded  the  dis- 
ease in  several  cases.  The  disease  may 
be  the  result  of  various  infections,  snch 
as  typhoid,  diphtheria,  and  septicaemia. 
The  resemblances  of  the  symptoms  to 
those  of  phosphorus  poisoning  are  un- 
doubted, but  there  are  essential  differ- 
ences in  the  resulting  morbid  changes 
that  render  it  clear  that  the  two  condi- 
tions are  not  identical.  In  view  of  the 
variety  of  conditions  under  which  the 
disease  occurs,  it  is  highly  probable  that 
it  is  due  to  various  forms  of  infection. 

Morbid  Anatomy. — The  liver  is 
greatly  reduced  in  size;  it  may  be  less 
than  half  its  normal  weight.  It  is  thin, 
flabby,  and  wrinkled  in  appearance. 

On  section  it  is  tough  rather  than 
firm.  The  cut  surface  varies  in  color 
from  a  yellowish  to  a  reddish  brown  and 
is  often  mottled  irregularly.  The  lobules 
are  small  and  indistinct;  in  the  parts 
most  advanced  in  degeneration  they  can- 
not be  distinguished. 

On  microscopical  examination  the 
liver-cells  are  found  greatly  degenerated, 
containing  swelled,  indistinct  nuclei  and 
fat-granules.  In  many  parts  they  have 
been  entirely  replaced  by  fat-granules 
and  debris  held  together  by  the  liver- 
stroma. 

Essential  anatomical  changes  in  yellow 
atrophy:  a  fatty  degeneration  and  necro- 
sis of  liver-cells,  produced  by  several  dif- 
ferent infections,  of  which  syphilis  may 
be  one.  E.  Meder  (Beitrage  zur  path. 
Anat.,  etc.,  B.  16,  p.  143,  '95)  ;  Marchand 
(Beitrage  zur  path.  Anat.,  etc.,  B.  1G,  p. 
206,  '95) ;  Huber  (La  Presse  Med.,  June 
19,  '95). 

Literature  of  'dQ-^dS. 

Case  of  acute  yellow  atrophy  of  the 
liver  in  a  boy  of  4  years.  At  the  autopsy 
there  was  cheesy  degeneration  of  the 
lymph-glands  at  the  root  of  the  lung; 


enlarged  spleen,  and  a  small,  firm,  tough 
liver,  filled  with  yellow  areas  and  some 
small  red  points.  Microscopically  the 
cells  showed  indefinite  contours,  poorly- 
staining  nuclei,  and  fatty  degeneration. 
The  central  veins  were  greatly  dilated 
and  surrounded  by  a  round-celled  infil- 
tration. Friederich  Lanz  (Wien.  klin. 
Woch.,  July  23,  '97). 

In  less  degenerated  parts  the  periphery 
of  the  lobules  is  most  affected  where  the 
cells  are  disintegrated  and  the  biliary 
canaliculi  distended  with  desquamated 
epithelium  and  granular  masses  of  bile- 
pigment,  constituting  a  complete  ob- 
struction to  the  flow  of  bile.  In  these 
parts  active  cell-division  may  be  found, 
as  if  an  effort  were  being  made  to  re- 
generate the  hepatic  parenchyma.  It  is 
possibly  due  to  this  activity  that  recov- 
ery takes  place  in  rare  cases. 

In  acute  yellow  atrophy,  the  poison, 
whatever  its  nature  may  be,  may  affect 
the  liver  very  unequally  and  in  different 
degree.  Thus,  in  the  same  liver  there 
may  be  found  areas  in  which  the  liver- 
cells  have  still  their  nuclei  well  preserved, 
others  in  which  the  cells  are  entirely  ne- 
crosed, and  others  again  in  which  the 
liver-cells  have  disappeared:  in  the  last, 
if  there  has  been  sufficient  time,  prolifer- 
ative changes  are  well  marked.  It  is  also 
quite  possible  that  in  certain  cases  the 
poison  may  act  only  locally,  and  that  re- 
covery may  take  place.  Stroebe  (Zieg- 
ler's  Beitrage,  vol.  xvii,  p.  206). 

The  larger  bile-ducts  are  usually  free 
from  bile,  containing  mucus  only;  the 
gall-bladder  often  contains  a  little  bile. 

Micro-organisms  of  various  kinds  have 
been  found  in  some  cases,  but  not  with 
such  constancy  as  to  indicate  that  they 
take  any  active  part  in  the  causation  of 
the  disease. 

These  briefly  were  the  conditions 
found  by  Prof.  A.  B.  Macallum  in  a 
case  of  mine  in  1800,  and  from  them 
he  concluded  that  the  disease  is  caused 
by  a  toxic  agent  carried  to  the  liver  by 


LIVER,  DISEASES  OF  THE.    ABSCESS.  SYMPTOMS. 


395 


the  portal  vein  and,  therefore,  originat- 
ing in  the  intestine  (Brit.  Med.  Jour., 
volume  i,  '94). 

There  is  general  bile-staining  of  other 
organs  and  tissues.    Numerous  haemor- 
rhages are  found  in  various  situations. 
The  heart,  voluntary  muscles,  and  renal 
epithelium  usually  show  fatty  degenera- 
tion.  The  spleen  is  large  and  there  may 
he  considerable  effusion  into  the  pleural 
and  pericardial  cavities.    There  are  evi- 
dences of  catarrh  in  the  digestive  tract. 
Case  of  acute  yellow  atrophy  compli- 
cated  with    multiple    cerebral  haemor- 
rhages.   Lafitte  (Bull,  de  la  Soc.  Anat., 
Xo.  16,  '91). 

Literature  of  '96-'97-'98. 

In  acute  yellow  atrophy  the  cord  may 
show  changes  which  seem  to  be,  like 
atrophy  of  the  liver,  the  result  of  the 
severe  general  intoxication.  Goldscheider 
and  Moxter  (Fortschritte  der  Med.,  Xo. 
14,  '97). 

Pkogxosis. — The  disease  is  so  fatal 
that  recovery  almost  implies  a  mistake 
in  diagnosis. 

The  statistics  of  the  Havana  Civil  Hos- 
pital show  that  acute  yellow  atrophy  is 
by  no  means  necessarily  fatal,  as  there 
have  been  11  recoveries,  besides  1  which 
was  returned  as  improved.  Martinez 
(Rev.  de  las  Ciencias  Med.,  p.  100,  '89). 

Case  of  favorable  termination  of  acute 
yellow  atrophy,  it  being  the  sixteenth  on 
record.  The  patient  was  nourished  for  a 
month  by  rectal  injection  of  peptone, 
eggs,  and  milk.  Weising  (Schmidt's 
Jahrbucher,  Aug.  15,  '92). 

Treatment. — Tin's  is  purely  sympto- 
matic. There  are  no  remedies  known  to 
have  any  influence  on  the  disease. 

Treatment  is  never  very  effectual  in 
acute  yellow  atrophy,  but  the  main  in- 
dications are  to  be  met  at  first  by  cathar- 
tics and  later  by  tonics.  Martinez  (Rev. 
de  las  Ciencias  Med.,  p.  100,  '89). 

Abscess  of  the  Liver. 

Symptoms. — The  outset  of  I  lie  disease 


is  always  insidious  and  the  course  may 
be  latent  throughout,  an  unsuspected 
abscess  being  found  at  the  autopsy. 
When  not  latent,  the  cardinal  symptoms 
are:  fever,  with  free  perspiration,  pain, 
enlargement  of  the  liver,  and  signs  of 
septic  infection.  There  is  loss  of  appe- 
tite, more  or  less  rapid  emaciation  and 
increasing  weakness  and  anaemia.  There 
|  is  a  sense  of  weight  and  distress  in  the 
epigastric  and  right  hypochondriac  re- 
gions, with  sometimes  hiccough,  nausea, 
and  even  vomiting.  An  icteroid  hue  de- 
I  velops,  rarely,  marked  jaundice.  The 
|  temperature  is  elevated  from  the  first 
and  is  of  a  septic  character.  It  is  ir- 
regular, being  normal  at  times,  then 
rising  to  103  or  more,  with  a  more  or 
less  marked  chili,  to  defervesce  again 
with  profuse  sweating.  These  variations 
may  be  so  regular  as  to  clearly  simulate 
malarial  fever,  but  the  variations  lose 
their  regularity  in  a  few  days.  In  other 
cases  typhoid  fever  is  simulated.  With 
the  evacuation  of  the  pus,  the  temper- 
ature may  fall  to  normal  and  remain 
so;  much  will  depend  on  the  thickness 
of  the  abscess-wall  and  whether  other 
foci  of  suppuration  co-exist.  The  pulse- 
rate  varies  in  general  with  the  tempera- 
ture, but  toward  the  end  of  life  it  be- 
comes greatly  accelerated  and  feeble. 

Pain  is  variable,  and  probably  is  not 
present  until  the  abscess  approaches  the 
surface  of  the  liver.  It  is  usually  re- 
ferred to  the  scapular  region,  but  may 
be  felt  in  the  region  of  the  liver.  The 
patient  usually  finds  lying  on  the  back 
or  right  side  most  comfortable;  on  the 
left  side  the  liver  drasrs  on  its  liffa- 

o  o 

ments  and  any  inflammatory  adhesions 
i  that  may  be  formed  and  causes  discom- 
I  fort.     Pressure  at  the  costal  margin, 
:  especially  in  the  nipple-line,  is  usually 
painful. 

Enlargement   of  the  liver  is  most 


396  LIVER,  DISEASES  OF  THE. 

marked  in  the  right  lobe,  and  may  be 
more  apparent  in  the  erect  posture.  In 
multiple  abscesses  and  pylephlebitis  the 
enlargement  is  general  and  rarely  great. 
In  tropical  abscess  when  situated,  as  it 
usually  is,  in  the  dome  of  the  liver,  the 
enlargement  is  chiefly  upward,  contrast- 
ing with  the  downward  enlargement 
usual  in  new  growths  of  the  liver.  The 
area  of  thoracic  dullness  may  be  sharply 
convex  upward  and  rise  to  the  fifth  rib 
in  the  midaxillary  line  and  posteriorly 
to  the  angle  of  the  scapula.  It  has  been 
reported  to  even  reach  the  second  rib  in 
front  and  the  spine  of  the  scapula  be- 
hind. In  these  cases  of  extremely  large 
abscess  the  right  side  is  bulged  and  the 
lower  margin  of  the  liver  depressed,  it 
may  be,  to  the  iliac  crest;  over  the  liver 
there  is  tenderness  and  often  crepitus  to 
palpation;  and  occasionally  fluctuation 
may  be  elicited. 

No  local  pain  in  hepatic  abscess,  except 
in  rare  instances.  Tschernow  (Wratsch, 
Nos.  35,  30.  '94). 

Two  cases  of  abscess  of  the  liver  in 
army-officers,  aged  28  and  27  years,  re- 
spectively. In  each  case  dysentery  had 
preceded  the  hepatic  abscess,  and  the  pus 
had  made  its  exit  through  the  bronchial 
tubes.  The  symptoms  were  extreme  ema- 
ciation and  anaemia,  a  constant  cough 
with  very  free  expectoration  of  pus,  fever 
varying  from  102°  to  103.5°  F..  a  good 
appetite,  and  no  diarrhoea.  Both  made 
good  recoveries.  Ferron  (Jour,  de  Med. 
de  Bordeaux.  Apr.  23,  '93). 

Literature  of  ,96-,97-'98. 

The  absence  of  rigors  is  more  often 
a  feature  of  chronic  abscess  than  of  acute. 
Ureschfeld  (Med.  Chronicle,  June  1.  !»7). 

Tropical  abscess  of  the  liver  may  run 
its  entire  course  wit  limit  giving  any  sub- 
jective symptoms  thai  would  attract  the 
physician's  attention  to  the  liver. 

Absorption-icterus  is  rare  in  tropical 
abscess.  In  the  cases  of  abscess  of  porta] 
origin  icterus  is  relatively  more  frequent. 
The  involvement,  of  the  peritoneal  cover- 


ABSCESS.  SYMPTOMS. 

ing  of  the  liver  causes  severe  pain  on  res- 
piration. 

Involvement  of  the  phrenic  nerve  and 
the  diaphragm  is  responsible  for  some  of 
the  most  constant  manifestations  of  he- 
patic abscess  of  amoebic  origin.  Pain 
may  be  referred  to  the  shoulder-joint; 
scapular,  clavicular,  or  deltoid  region; 
or  to  the  side  of  the  neck,  or  may  even 
extend  down  the  inner  aspect  of  the  arm 
and  forearm. 

The  pain  may  be  sharp,  lancinating, 
or  dull,  or  simply  a  sense  of  tension  or 
fullness  in  this  region. 

Tussis  hepatica  is  due  to  phrenic  irrita- 
tion;  it  may  occur  with  abscess  or  gall- 
stones.    Hiccough  is  produced  through 
the  agency  of  the  phrenic  nerve.   The  pa- 
tient may  suffer  with  dyspnoea.    W.  T. 
Howard,  Jr..  and  C.  F.  Hoover  (Amer. 
Jour.  Med.  Sci.,  Sept.,  '97). 
Owing  to  the  frequent  situation  of  the 
abscess  in  the  dome  of  the  liver,  im- 
plication of  the  lung  is  more  frequent 
in  the  tropical,  or  amoebic,  cases  than  in 
the  septic  ones  occurring  in  our  north- 
ern climates.    The  pulmonary  symptoms 
often  occur  early  and  become  so  pro- 
nounced as  to  obscure  the  hepatic  symp- 
toms.   They  usually  consist  of  stitch- 
like pain  and  signs  of  exudation  into  the 
pleura  in  the  right  axillary  region,  dysp- 
noea, and  lacking  cough  with  little  ex- 
pectoration.    Later,  when  the  abscess 
discharges  into  the  bronchi,  severe  par- 
oxysmal cough  develops,  with  abundant 
expectoration,  often  greatly  increased  on 
lying  down.    The  sputum  consists  of  a 
"dirty-red  or  brownish  puriform  matter. 
There  is  no  matter  like  it  expectorated 
in  any  disease  of  the  lung  itself,  and  I 
believe  that  its  appearance  is  pathogno- 
monic of  abscess  of  the  liver,  or,  at  least, 
of  abscess  perforating  the  lung"  (Budd). 

Literature  of  '96-'97-'dS. 

Case  of  abscess  of  the  liver  discharging 
through  the  lung.  After  several  unsuc- 
cessful attempts,  the  abscess  was  dis- 
covered and  drained.  C.  A.  Morton 
(Lancet,  Aug.  S,  '<)(>). 


LIVER,  DISEASES  OF  THE.    ABSCESS.    DIAGNOSIS.  397 


Liver-abscesses  may  communicate  with 
various  organs  and  cavities.  The  most 
common  secondary  invasion  is  un- 
doubtedly through  the  diaphragm  into 
either  the  right  pleural  sac  or  directly 
into  the  lower  lobe  of  the  right  lung. 
Thierf elder  collected  170  cases  of  liver- 
abscess,  of  which  76  opened  into  the  lung 
and  bronchi,  23  into  the  abdominal 
cavity,  32  into  the  intestine,  and  13  into 
the  stomach.  Aghetti  collected  131  cases, 
of  which  38  broke  into  the  lung.  W.  T. 
Howard,  Jr.,  and  C.  F.  Hoover  (Amer. 
Jour.  Med.  Sci.,  Aug.,  '97). 

Two  cases  of  amoebic  abscess  of  the 
liver  reported,  together  with  the  only  one 
that  could  be  found  in  the  literature  in 
which  secondary  perforation  of  the  in- 
ferior vena  cava  resulted.  Flexner 
(Amer.  Jour.  Med.  Sci.,  May,  '97). 

A  slight  degree  of  jaundice  is  not 
rare;  it  may  vary  with  the  variations 
of  temperature.  Exceptionally  more 
marked  and  prolonged  jaundice  is  caused 
by  pressure  of  the  abscess  on  the  com- 
mon bile-duct.  Ascites  may  result  in  a 
similar  manner  from  pressure  on  the  por- 
tal vein. 

Diagnosis. — As  the  suppurative  proc- 
ess in  the  liver  may  be  latent,  it  is  often 
impossible  to  make  a  diagnosis  of  hepatic 
abscess,  especially  in  the  early  stage. 

The  occurrence  of  pain  in  the  right 
hypochondrium  or  in  the  scapular  re- 
gion, some  enlargement  and  tenderness 
of  the  liver,  and  irregular  fever,  usually 
with  chills  more  or  less  marked,  in  a 
case  with  a  history  of  ulcerative  proc- 
esses anywhere  in  the  digestive  tract 
affords  fairly  certain  ground  for  a  diag- 
nosis. 

Attention  called  to  the  perihepatic 
friction  in  suppurating  hepatitis  as  a  di- 
agnostic  sign  that  may  be  perceived  both 
by  ear  and  hand,  and  precedes  by  several 
days  (edema  of  the  parts.  It  is  also  evi- 
dence that  the  liver  is  fixed  to  the  ab- 
dominal walls  by  adhesive  peritonitis. 
Bertrand  (La  Sem.  Med..  Mar.  9,  "90). 

Diagnosis  of  suppurative  hepatitis 
based  upon  localization  of  the  pain,  with 


irradiation  to  the  shoulder,  the  nature  of 
the  temperature-curve,  and  the  exclusion 
of  pleurisy.  Barthelemy  and  Bernardy 
(Archives  de  Med.  et  de  Pharm.  Milit., 
Apr.,  '90). 

The  apparent  enlargement  of  the  liver, 
in  a  case  in  which  abscess  or  cancer  had 
been  suspected,  was  apparent  only,  and 
^  was  the  result  of  a  localized  peritonitis, 
.which  had  pushed  the  liver  down.  The 
organ  was  held  down  by  fibrous  bands, 
the  result  of  organized  lymph.  Pepper 
(Univ.  Med.  Mag..  Aug.,  '91). 

If  discharge  takes  place  through  the 
lung  the  character  of  the  pus  may  be 
sufficient  to  establish  the  diagnosis;  espe- 
cially if  amoeba  be  found  in  it,  otherwise 
abscess  of  the  lung  or  empyema  will  have 
to  be  excluded. 

Case  in  which  the  diagnosis  rested  upon 
the  presence  of  amoeba  coli  in  the  sputum. 
Symptoms  were  constipation;  pain  in 
side:  cough,  with  blood-stained  sputum; 
stools  containing  mucus  and  blood;  no 
chills,  but  fever  at  times  and  sweats. 
Later,  sputum  resembled  anchovy-sauce; 
actively-moving  amoebas  were  found  in 
it;  liver  enlarged  behind;  dullness  at 
base  of  right  lung  and  feeble  breathing, 
which  at  angle  of  scapula  was  tubular, 
with  large  rales.  Had  amoebae  not  been 
found,  the  case  would  have  been  regarded 
as  one  of  pleurisy.  Simon  (Johns  Hop- 
kins Hosp.  Bull.,  Nov.,  '90). 

Case  of  multiple  liver-abscess,  second- 
ary to  pelvic  peritonitis,  following  sal- 
pingitis. Patient  was  supposed  to  be  suf- 
fering from  phthisis.  There  were  no  defi- 
nite symptoms  calling  attention  to  the 
liver  or  pelvic  viscera.  De  Silva  (Ceylon 
Med.  Jour..  July.  '90). 

Case  in  which  the  diagnosis  of  em- 
pyema was  made,  because  exploratory 
puncture  and  the  physical  signs  pointed 
to  this  condition.  At  the  autopsy  abso- 
lutely nothing  was  found  in  the  pleura] 
cavities  except  a  very  slight  pleuritis  on 
the  right  side.  In  the  posterior  and  upper 
part  of  the  right  lobe  of  the  liver,  how- 
ever, was  a  very  large  abscess-cavity, 
which  communicated  with  the  operation- 
wound.  The  diaphragm  was  intact. 
J.  M.  Byron  (Med.  Rec.,  Aug.  4.  "94). 


398 


LIVER,  DISEASES  OF  THE.    ABSCESS.  DIAGNOSIS. 


Literature  of  '96-'97-'98. 

Of  diseases  in  the  liver-region  abscesses 
of  the  base  of  the  right  lung  are  not  un- 
common and  present  many  features  of 
similarity.  In  both  there  is  increased  I 
area  of  dullness,  pain  is  similar  in  char- 
acter and  location,  cough  is  a  feature  of 
each,  and  the  constitutional  symptoms 
are  more  or  less  parallel.  The  history 
leading  up  to  the  illness  is  quite  dissimi- 
lar in  most  instances.  Pulmonary  abscess 
is  constantly  preceded  by  pneumonia;  | 
hepatic  abscess  by  dysentery,  suppurative 
processes  within  the  bounds  of  the  portal 
system,  or  suppurative  cholangitis.  The 
sputum  from  a  ruptured  abscess  of  the 
lung  is  of  purulent  nature,  stained  with 
blood,  while  that  from  abscess  of  the  liver 
is  often  of  reddish-brown  color,  like  an- 
chovy-sauce. 

The  pulsating  pleurisy,  encysted  em- 
pyema, and  subphrenic  abscess  are  also 
affections  extremely  difficult  and  often 
impossible  of  differential  diagnosis.  In 
pyothorax  dyspnoea  is  ordinarily  more 
pronounced,  and  there  may  be  a  slight 
resonant  space  between  the  pleural  pus- 
collection  and  the  liver. 

In  suppurative  appendicitis,  the  previ- 
ous history,  the  presence  of  the  tumor, 
the  location  of  the  pain,  the  resistance  of 
the  abdominal  muscles,  together  with  the 
absence  of  functional  disturbances  of  the 
liver,  generally  suffice  to  clear  away  all 
doubt. 

In  paranephric  or  perinephric  abscess 
of  the  right  kidney  it  is  well  to  remember 
that  this  is  frequently  the  result  of  dis- 
ease of  the  kidney,  or  by  extension  of  in- 
flammation from  neighboring  parts,  that 
its  origin  is  never  spontaneous,  that  it 
occurs  twice  as  often  in  adult  males  as 
in  females.  Pain  and  swelling  in  the  lum- 
bar region  are  the  localizing  symptom*. 
John  G.  Cecil  (Amer.  Pract.  and  News. 
Apr.  17,  '97). 

Perforation  externally  may  render 
diagnosis  easy.  If  the  abscess  is  in  the 
liver  the  needle  inserted  into  it  will  move 
with  the  respiratory  movements  of  the  I 
liver  unless  adhesions  he  so  firm  that 
the  liver  is  quite  fixed.  Empyema  of 
the  gall-bladder  would,  of  course,  move 


with  the  liver,  as  might  also  an  abscess 
adherent  to  the  under  surface  of  the 
liver. 

Attacks  of  gall-stone  colic  with 
marked  intermittent  fever  often  closely 
simulate  hepatic  abscess.  In  the  gall- 
stone cases  the  attacks  of  fever  are  par- 
oxysmal, with  severe  pain,  and  sweat- 
ing. The  attacks  may  recur  with  great 
regularity.  In  the  intervals  between  the 
attacks  there  is  complete  apyrexia,  and 
the  general  nutrition  is  well  maintained. 
Such  a  history  may  be  continued  for 
years. 

Case  in  which  abscess  gave  passage  to 
thirty  gall-stones.  Covert  (Chicago  Med. 
Times,  Aug.,  '95). 

As  abscess  of  the  liver  is  a  secondary 
affection,  the  previous  history  is  impor- 
tant. The  primary  disease  may  be  dys- 
entery, ulcer  of  the  stomach,  haemor- 
rhoids, rectal  ulcers,  appendicitis,  etc. 

Case  of  hepatic  abscess  at  first  diag- 
nosed as  tertian  ague,  and  always  relieved 
while  under  quinine,  but  always  recur- 
ring. Later,  the  correct  diagnosis  was 
made  and  operation  performed.  J.  J. 
Bland  (New  Orleans  Med.  and  Surg. 
Jour.,  Aug.,  '90). 

Fatal  case  of  hepatic  abscess,  in  which 
during  life  a  diagnosis  of  cancer  had  been 
made.  Bezancon  (Bull,  de  la  Soc.  Anat., 
Jan.,  '94). 

Case  of  hepatic  abscess  simulating  ulcer 
of  the  stomach.  Texier  (Le  Bull.  Med., 
June  2,  '95). 

Literature  of  '96-'97-'98. 

Certain  cases  of  enteric  fever  present  a 
clinical  picture  resembling  liver-abscess. 
The  type  and  course  of  typhoid,  when  un- 
modified by  antipyretics,  in  comparison 
with  the  more  erratic  chill,  fever,  and 
sweat  of  hepatic  abscess  is  sufficient,  to- 
gether with  the  other  usual  manifesta- 
tions of  typhoid,  to  make  the  distinction 
clear. 

Cancer  of  the  liver  differs  from  an  ab- 
scess by  its  dissimilar  history,  by  the 
hard  nodular  masses,  and  by  absence  of 
fluctuations.    Further,  the  marked  fever 


LIVER,  DISEASES  OF  THE.    ABSCESS.  ETIOLOGY. 


399 


and  other  constitutional  symptoms  are 
not  like  what  occurs  in  hepatic  cancer.  In 
cancers  the  superficial  veins  are  enlarged 
and  oedema  of  lower  extremities  common. 
From  a  suppurating  hydatid  cyst  of  the 
liver  an  abscess  can  scarcely  be  diagnosti- 
cated. John  G.  Cecil  (Amer.  Pract.  and 
News,  Apr.  17,  '97). 

The  most  common  error  is  to  regard 
the  hectic  of  liver-abscess  as  attributable 
to  malaria.  If  carefully  considered  there 
are  several  circumstances  which  should 
obviate  this  error:  — 

1.  No  uncomplicated  ague  resists  qui- 
nine in  full  doses. 

2.  In  malaria,  if  the  liver  be  enlarged, 
the  spleen  is  still  more  so;  the  reverse 
is  the  case  in  liver-abscess. 

3.  The  plasmodium  cannot  be  found  in 
the  blood  in  non-malarial  hepatitis. 

4.  In  liver-abscess  the  fever  is  almost 
invariably  an  evening  one;  in  malaria 
it  most  frequently  comes  on  earlier  in  the 
day. 

5.  Quotidian  periodicity,  contrary  to 
what  is  the  case  with  tertian  or  quartan 
periodicity,  is  by  no  means  pathogno- 
monic of  nor  peculiar  to  malaria. 

6.  The  almost  invariable  history  of 
antecedent  dysentery  or,  at  least,  of 
intestinal  disorder  in  liver-abscess.  Ed. 
E.  Field  (Ga.  Jour.  Med.  and  Surg.,  Dec, 
'98). 

The  existence  of  leucocytosis  may 
prove  of  importance  as  indicative  of  sup- 
puration. The  diagnosis  may  sometimes 
be  established  by  aspiration:  an  opera- 
tion that  may  be  resorted  to  without  any 
great  degree  of  danger.  Of  course,  fail- 
ure to  find  pus  does  not  negate  the  ex- 
istence of  abscess,  as  the  needle  may 
not  reach  it  or  the  contents  may  be  too 
thick  to  enter  the  needle.  The  patient 
should  1)0  anaesthetized,  as  many  punct- 
ures may  be  required.  The  needle 
should  bo  inserted  in  the  lowest  inter- 
space in  the  anterior  axillary  line,  in  the 
seventh  interspace  in  the  midaxillary 
line,  or  in  the  centre  of  the  dull  area 
behind.  The  needle  should  bo  used  only 
to  determino  the  necessity  for  drainage. 


Etiology. — Abscess  of  the  liver  results 
occasionally  from  traumatism,  as  from  a 
blow  or  a  punctured  wound. 

Abscess  of  the  liver  is  very  rare  in  chil- 
dren. From  study  of  37  cases  the  aver- 
age of  occurrence  was  found  to  be  a  little 
less  than  nine  years.  The  youngest  was 
an  infant  of  one  year;  the  oldest  fifteen 
years  old.  Injury  was  the  assigned  cause 
in  9  cases.  The  next  most  frequently  as- 
signed case  is  round  worms,  which  have 
migrated  from  the  intestine  into  the  bile- 
ducts  and  there  set  up  an  inflammation. 
In  the  remaining  cases  the  abscess  was 
secondary  to  a  pylephlebitis  in  4  cases, 
to  an  umbilical  phlebitis  in  1,  to  pyaemia 
in  2,  to  dysentery  in  3,  to  pelvic  perito- 
nitis, perityphlitis,  malarial  fever,  and 
tuberculosis  of  the  lungs  in  1  each.  R.  M. 
Slaughter  (Virginia  Med.  Monthly,  Oct.. 
'95). 

Apart  from  traumatism,  the  two  chief 
avenues  by  which  bacteria  gain  access  to 
the  liver  and  excite  suppuration  are  the 
portal  vein  and  the  bile-ducts.  Of  these, 
the  portal  vein  is  the  chief  one,  as  it  may 
convey  germs  from  any  part  of  the  di- 
gestive tract;  hence  the  frequency  with 
which  abscess  of  the  liver  follows  ulcer- 
ating lesions  of  the  intestines,  as  dys- 
entery, appendicitis,  haemorrhoids,  and 
other  rectal  diseases. 

Abscess  of  the  liver  is  a  micro-organ- 
ismal  disease,  the  principal  factor  being  a 
streptococcus.  Dysentery  is  a  disease  of 
the  same  character,  produced  by  a  strep- 
tococcus. The  point  of  entrance  of  micro- 
organisms found  in  the  liver  is  chiefly  the 
intestinal  tract,  whence  they  pass  to  the 
liver  either  with  the  portal  blood  or  the 
general  circulation.  Zancarol  (Revue  de 
Chir.,  Aug.  10,  '93). 

At  autopsy  of  case  of  hepatic  abscess 
several  calculi  were  found,  the  largest  of 
which  had  become  impacted  in  the  ductus 
choledochus.  and  by  pressure  on  the  por- 
tal vein  had  led  to  the  formation  of  a 
thrombus.  This  had  later  broken  down 
and  become  the  source  of  multiple  ab- 
scesses. Geige]  (Zeit.  f.  klin.  Med..  1?.  16, 
H.  3.  4.  \S9). 

Formation  of  gall-stones  regarded  as 


400 


LIVER,  DISEASES  OF  THE.    ABSCESS.  ETIOLOGY. 


most  frequent  cause  of  liver-abscess  in 
Germany.  W.  Korte  (Deut.  med.-Zeit., 
July  28,  '92). 

Case  of  abscess  due  to  duodenal  ulcera- 
tion caused  by  extensive  burns,  pus  con- 
taining ordinary  micrococci.  Hehir  (In- 
dian Med.  Record,  June  16,  '95). 

Abscess  in  which  pus  showed  tubercle 
bacilli.    Churton  (Lancet,  Mar.  9,  '95). 

A  case  of  abscess  of  the  liver  following 
typhoid  fever  in  which  the  pus  of  the 
abscess  contained  the  bacillus  of  typhoid. 
Abscesses  of  the  liver  following  this  dis- 
ease divided  into  those  due  to  metastasis, 
those  due  to  typhoid  ulceration  of  the 
biliary  passages,  and  those  due  to  typhoid 
pyelophlebitis.  Lannois  (Rev.  de  Med., 
Nov.,  '95). 

Emboli  from  these  sources  may  excite 
suppurative  pylephlebitis,  from  which 
abscesses  may  result  by  extension  into 
the  liver-substance. 

A  case  of  abscess  of  the  liver  due  to 
pylephlebitis  following  typhoid  fever. 
Schultz  found  no  instances  among  3686 
patients  with  362  fatal  cases;  Romberg 
saw  1  among  677  cases,  with  88  deaths; 
Dopfer  saw  10  in  927  autopsies.  There 
was  no  cause  for  metastatic  abscess  nor 
any  typhoid  ulceration  of  the  biliary  pas- 
sages or  gall-bladder.  The  abscess  was 
due  to  ascending  thrombosis  beginning  in 
the  intestines,  and  the  bacillus  of  Eberth 
M  as  found  in  the  abscess.  Lannois  (Rev. 
de  Med.,  Nov.,  '95). 

Literature  of  96-'97-'98. 

A  case  of  abscess  of  the  liver  which 
developed  a  few  months  after  perityph- 
litis. FrankePs  diplococci  were  found  in 
the  pus.  Hermes  (Deut.  Zeit.  f.  Chir., 
No.  6,  '96). 

Infective  processes  in  the  umbilical 
cord  in  infants  may  extend  along  the 
vein  to  the  liver  and  produce  one  or  more 
abscesses.  In  a  similar  manner  they  may 
result  from  abscess  of  the  spleen. 

In  general  pyaemia  abscess  of  the  liver 
is  rare,  as  the  germs  have  to  pass  through 
the  lungs  to  reach  the  liver.  Suppura- 
tive wounds  of  the  head  are.  however, 
followed  by  hepatic  abscess  with  com- 


parative frequency.  It  may  possibly 
happen  in  these  cases  that  the  infectious 
agent  reaches  the  hepatic  veins  by  "re- 
trogressive embolism"  from  the  vena 
cava. 

Next  to  the  portal  vein,  the  most  com- 
mon avenue  of  invasion  of  the  liver  by 
pyogenic  organisms  is  the  bile-duct. 
The  germs  originate  in  the  intestine, 
and  the  inflammation  resulting  from 
their  presence  in  the  duct  is  probably 
always  preceded  by  injury,  usually  from 
pressure  of  a  gall-stone,  more  rarely  from 
the  irritation  of  a  parasite. 

Literature  of  'M-W-'dS. 

Abscess  of  the  liver  caused  by  a  pin. 
Both  the  head  and  the  stem  of  the  pin 
were  incased  in  calcareous  matter,  so  that 
it  measured  nearly  three  millimetres  in 
diameter.  Alexander  Lambert  (X.  Y. 
Med.  Jour.,  Feb.  5,  '98). 

In  tropical  climates  there  is  close  as- 
sociation between  abscess  of  the  liver  and 
dysentery:  an  association  apparently  ex- 
plained by  the  discovery  of  the  presence 
in  both  of  the  amoeba  coli.  But  the 
amoeba  is  not  found  in  all  cases  of  hepatic 
abscess  in  hot  climates,  and  probably 
other  organisms  are  the  active  agents  in 
the  production  of  many  cases. 

Attempt  made  to  explain  the  connec- 
tion between  dysentery  and  hepatic  ab- 
scess. In  the  intestinal  ulcers  of  over 
500  cases  of  dysenteric  origin  amoeba? 
(proteus  vulgaris)  were  discovered,  while 
they  could  not  be  found  in  abscesses  due 
to  other  causes.  Sharp  distinction  to  be 
drawn  between  dysenteric  and  idiopathic 
tropical  abscesses  which  arc  due  to  pyog- 
enic micro-organisms  coming  probably 
from  the  gastro-intestinal  tract.  Kar- 
tnlis  (Virchow's  Archiv,  Oct..  '89). 

In  a  tropical  hepatic  abscess  not  de- 
pendent upon  dysentery,  pure  cultures  of 
staphylococcus  pyogenes  aniens  found. 
Amo'b;c  were  not  present.  Macfadyen 
(Brit  Med.  Jour.,  .inly  15.  '93). 

Several  cases  of  multiple  abscess  of  the 
liver  reported.    In  the  pus  of.  one.  the 


LIVER,  DISEASES  OF  THE.    ABSCESS.    MORBID  ANATOMY. 


401 


staphylococcus  pyogenes  albus;  in  an- 
other, the  staphylococcus  pyogenes 
aureus  and  a  streptococcus;  in  a  third, 
a  staphylococcus  and  the  bacterium  coli 
commune  were  found.  Clark  (Practi- 
tioner, Oct.,  '93). 

Bacteriological  examination  of  the  pus 
of  an  abscess  of  the  liver  following  dysen- 
tery revealed  many  micro-organisms,  as 
the  staphylococcus  pyogenes,  the  bacillus 
of  Eberth,  and  a  microbe  not  yet  deter- 
mined. The  pus  of  these  abscesses  is  not 
sterile,  or  such  a  sterility  is  only  appar- 
ent. Nertrand  (Le  Bull.  Med.,  Apr.  18. 
'94). 

Sterile  pus  is  found  mostly  in  old  ab- 
scesses, while  the  acute  ones  contain 
micro-organisms;  therefore,  hepatic  ab- 
scesses are  of  microbic  origin,  but  the 
microbes  die  rapidly  in  their  pus.  Lav- 
eran  (Le  Bull.  Med.,  Dec.  6,  '93). 

Literature  of  '96-'97-'98. 

A  case  of  dysentery  followed  by  abscess 
of  the  liver  in  which  the  amoeba  coli  was 
found  in  the  abscess-cavities,  though  none 
was  discovered  in  the  intestines  post- 
mortem. Manner  (Wien.  klin.  Woch., 
Feb.  20,  '96). 

The  statistics  collected  by  Councilman 
and  Lafleur  show  that  in  India  in  1429 
autopsies  on  persons  dying  of  dysentery, 
liver-abscess  occurred  in  306.  In  Algiers, 
of  1001  autopsies  on  dysenteric  cases,  180 
had  liver-abscess.  According  to  Kartulis, 
of  500  cases  of  dysentery,  from  50  to  60 
per  cent,  had  liver-abscess.  Of  40  Ameri- 
can cases  personally  collected,  18  had 
liver-abscess.  Liver-abscess  may  occur  in 
the  acute  form  of  dysentery,  but  it  is 
more  common  in  the  chronic  variety. 
W.  T.  Howard,  Jr.,  and  C.  F.  Hoover 
(Amer.  Jour.  Med.  Sci.,  Aug.,  '97). 

Bacteria  are  not  uncommonly  associ- 
ated with  amoebae  in  the  liver-abscesses 
and  lung-abscesses,  as  well  as  m  the  in- 
testinal lesions. 

While  careful  search  practically  al- 
ways demonstrates  the  presence  of 
amoebae  in  the  secondary  liver,  lung,  and 
pleural  abscesses  occurring  during  the 
course  of  or  following  amoebic  dysentery, 
very  little  is  known  of  the  etiology  of  the 
so-called  ''idiopathic"  abscesses  of  the 
liver. 


It  is  not  impossible  that  least  some 
cases  of  the  idiopathic  liver-abscesses  are 
caused  by  amoebae  that  have  penetrated 
to  the  submucosa  of  the  intestine  possibly 
through  small  breaks  in  the  mucous  mem- 
brane or  even  through  the  unbroken 
mucous  membrane,  causing  only  slight 
local  lesions,  and,  getting  into  the  lumen 
of  small  veins,  may  reach  the  liver.  An- 
other possibility  is  the  presence  of  one 
or  more  small  amoebic  ulcers  in  the  rec- 
tum, colon,  or  caecum,  or  even  the  small 
intestine  or  the  stomach,  which  are  too 
small  and  insignificant  to  cause  diarrhoea 
or  other  symptoms.  W.  T.  Howard,  Jr., 
and  C.  F.  Hoover  (Amer.  Jour.  Med.  Sci., 
Sept.,  '97). 

There  is  a  special  form  of  dysentery  in 
which  amoebae  are  constantly  present  and 
also  in  the  pus  of  certain  tropical  ab- 
scesses of  liver  the  same  bodies  are  found. 
Amoebae  coli  have  been  found  in  the  stools 
of  patients  who  were  not  at  the  time  suf- 
fering from  dysentery.  This  fact  may 
account  for  some  cases  of  hepatic  abscess 
in  which  there  is  no  trace  of  a  dysenteric 
connection.  C.  W.  Windsor  (Lancet, 
Dec.  11,  '97). 

Hepatic  abscess  may  originate  in  pa- 
tients who  many  years  previously  have 
suffered  from  dysentery.  Josserand 
(Jour,  de  Med.,  July  25,  '98). 

Case  of  hepatic  abscess  without  history 
or  symptoms  of  dysentery;  yet  the 
amoeba  coli  was  found  in  abundance  in 
the  pus  which  escaped  after  incision. 
G.  R.  Turner  (Lancet,  Feb.  15,  '98). 

Morbid  Anatomy. — In  septic  cases  the 
abscesses  are  usually  multiple  and  irregu- 
larly distributed  throughout  both  lobes. 
Traumatism  may  give  rise  to  a  solitary 
abscess,  and  such  may  also  result  from  a 
single  embolus.  The  liver  is  usually 
uniformly  enlarged.  Its  surface  may 
present  no  abnormal  appearance.  In 
many  cases,  however,  there  are  yellowish 
points  showing  beneath  the  capsule.  On 
section  isolated  pockets  of  pus  are  found 
varying  in  size  from  a  small  point  up  to 
three  or  four  cubic  millimetres  or  more 
in  diameter,  the  larger  ones  being  prob- 
ably formed  by  the  coalescence  of  two  or 


402 


LIVER,  DISEASES  OF  THE.    ABSCESS.    MORBID  ANATOMY. 


more  smaller  abscesses.  Many  are  den- 
dritic in  form,  and  on  examination  are 
found  to  communicate  with  the  portal 
vein,  being  doubtless  formed  by  suppura- 
tion of  its  branches.  The  walls  of  the 
abscesses  are  shreddy,  especially  in  the 
larger  ones,  and  the  cavity  may  be  di- 
vided by  many  trabecule.  The  contents 
vary  according  to  the  age  of  the  abscess 
and  the  nature  of  the  infective  agent: 
they  may  be  thick  and  viscid;  or  foetid, 
bile-stained,  and  containing  masses  of 
necrotic  tissue;  or  the  pus  may  be  thick 
and  laudable.  All  the  branches  of  the 
portal  vein  in  the  liver  may  be  involved, 
but  sometimes  thrombi  circumscribe  the 
infection  and  preserve  sections  of  the 
liver  from  invasion.  The  suppurative 
process  may  extend  backward  even  into 
the  gastric  and  mesenteric  veins. 

Literature  of  '96-'97-'98. 

The  small  abscesses  may  be  microscop- 
ical in  size.  Their  contents  consist  of 
firmly  granular  material,  with  here  and 
there  cellular  and  nuclear  fragments,  and 
in  some  there  is  fibrin.  Few,  if  any,  leu- 
cocytes are  seen,  but  red  corpuscles  may 
be  numerous.  Amoeba?  are  always 
numerous  in  the  smaller  abscesses,  being 
more  numerous  about  the  periphery,  ex- 
tending in  places  into  the  liver-tissue, 
but  not  usually  beyond  the  area  of  tissue- 
necrosis.  A  few  may  be  found  in  the  cap- 
illaries. W.  T.  Howard,  Jr.,  and  C.  F. 
Hoover  (Amer.  Jour.  Med.  Sci.,  Aug., 
'97). 

If  infection  has  taken  place  through 
the  l>ile-ducts,  obstruction  by  gall-stones 
usually  exists  and  the  gall-bladder  and 
the  bile-ducts  generally  may  be  dilated 
and  full  of  pus,  often  bile-stained. 

Very  large  abscesses  may  result  from 
suppuration  around  echinococcic  cysts; 
their  nature  is  indicated  by  the  presence 
of  portions  of  the  cysts. 

Tropical  Abscess.  —  There  may  be 
one  or  more;  in  the  latter  case  there  is 


usually  one  larger  and  evidently  much 
older  than  the  others.  They  may  vary 
in  size  from  a  few  millimetres  in  diam- 
eter up  to  an  orange  or  even  to  a  child's 
head.  The  larger  abscesses  usually  oc- 
cupy the  right  lobe,  being  situated,  as  a 
rule,  at  the  under  surface  above  the 
hepatic  flexure  of  the  colon  or  in  the 
dome  of  the  liver  (Lafleur).  In  Waring's 
statistics  of  three  hundred  cases,  in  62 
per  cent,  there  was  only  a  single  abscess. 
The  small  multiple  abscesses  are  usually 
superficial.  In  the  smaller  abscesses, 
being  more  recent,  the  walls  are  shreddy 
and  not  sharply  defined  from  the  con- 
tiguous inflamed  liver-substance.  Their 
contents  vary  from  a  yellowish  gray  to 
a  reddish-brown  (due  to  the  presence  of 
blood),  and  often  contain  shreds  of 
necrotic  liver-tissue.  In  old  abscesses 
the  walls  are  firm,  thick,  and  fibrous. 
The  contents  of  all  the  abscesses  are 
chiefly  remarkable  in  the  small  number 
of  leucocytes  that  are  present. 

Literature  of  '96-'97-'98. 

When  the  abscess  is  single  it  is  far 
more  frequently  found  in  the  right  lobe 
and  nearer  to  the  upper  surface.  Waring 
found  that  out  of  288  cases  of  tropical 
abscess  177  were  single.  The  pus  from  a 
true  tropical  abscess  shows  a  complete 
absence  of  pyogenic  organisms.  Osier 
expresses  the  opinion  that  the  pus  of 
tropical  abscess  is  quite  free  from  py- 
ogenic bacteria.  Macfadyen  holds  that 
in  tropical  abscesses  pyogenic  organisms 
are  constantly  met  with,  staphylococcus 
pyogenes  aureus  being  the  commonest, 
while  the  staphylococcus  albus  and 
streptococcus  pyogenes  are  often  found. 
C.  W.  Windsor  (Lancet,  Dec.  4,  '97). 

Case  of  tropical  abscess  of  the  liver 
containing  the  amoeba  coli.  in  which  the 
discharge  from  the  abscess  was  examined 
from  day  to  day.  On  the  sixth  day  after 
the  operation  it  was  found  that  the 
leucocytes  had  very  greatly  increased, 
that  the  amoebae  were  rapidly  disappear- 
ing.  and  that,  while  bacteria  had  previ- 


LIVER,  DISEASES  OF  THE. 


ABSCESS.  TREATMENT. 


403 


ously  been  absent,  there  had  now  ap- 
peared Frankel's  pneumococei,  strepto- 
cocci, and  the  colon  bacillus.  Peyrot  and 
Roger  (Rev.  de  Chir.,  Feb.,  '97). 

When  the  abscess  reaches  the  surface 
it  may  rupture  and  pus  escape  into  the 
peritoneal  cavity,  or,  adhesions  having 
previously  formed,  the  pus  may  pene- 
trate in  any  direction.  It  may  discharge 
into  the  stomach,  the  intestine,  the 
pelvis  of  the  right  kidney,  or  through 
the  diaphragm  into  the  pleural  or  peri- 
cardial sac.  Adhesion  of  the  lung  to  the 
diaphragm  usually  precedes  its  advent 
in  this  direction,  and  then  the  lung  is 
invaded,  an  abscess  forming  and  dis- 
charging into  the  bronchi.  It  may  also 
perforate  the  thoracic  wall  and  appear 
beneath  the  skin. 

Prognosis.  —  Suppurative  hepatitis  is 
a  grave  disease,  the  mortality  being  over 
50  per  cent.  In  rare  cases  of  single 
small  abscesses  and  of  mild  cases  of 
pylephlebitis  recovery  possibly  takes 
place  by  absorption  or  inspissation  and 
calcification  of  the  pus.  There  is,  how- 
ever, room  for  doubt  as  to  the  diagnosis 
of  such  cases.  Multiple  small  abscesses 
are  almost  necessarily  fatal,  as  they  can 
rarely  be  evacuated  either  by  natural 
processes  or  by  surgical  intervention.  In 
large  abscesses  the  mortality  has  been 
greatly  reduced  of  late  by  the  greater 
fearlessness  and  thoroughness  with  which 
they  are  operated  on.  Operation  appears 
to  give  much  better  results  in  the  ordi- 
nary septic  abscesses  than  in  the  amoebic 
variety. 

Out  of  88,416  deaths  in  ten  years,  in 
the  city  of  Mexico,  1985  were  due  to  hepa- 
titis. Symptoms  are  jaundice,  increasing 
in  severity;  signs  of  suppuration;  com- 
pression of  portal  vein ;  rarely  ascites ; 
liver  enlarged,  but  not  the  spleen.  On 
section,  the  liver  shows  many,  sometimes 
even  200.  abscesses  filled  with  a  white  or 
yellow-green  pus.  Mejia  (La  Sem.  Med., 
Aug.  27,  '90). 


Literature  of  '96-'97-'98. 

Cases  of  abscess  of  the  liver  usually 
terminate  favorably  after  rupture  into 
the  lungs.  T.  Glover  Lyon  (Lancet,  Nov. 
20,  '97). 

Treatment.  —  Apart  from  surgical 
means,  little  can  be  done,  beyond  re- 
lieving symptoms  and  maintaining  the 
patient's  strength,  until  the  abscess  dis- 
charges spontaneously  or  is  accessible  to 
the  surgeon.  Pain  and  cough  are  the 
chief  symptoms  to  be  relieved.  In  cases 
of  rupture  into  the  bronchi,  cough  is 
necessary  for  the  removal  of  the  pus, 
and  should  not  be  interfered  with  unless 
excessive. 

In  multiple  abscesses  and  in  suppura- 
tive pylephlebitis  surgical  measures  are 
useless  unless  to  open  an  abscess  threat- 
ening to  rupture.    In  single  abscesses 
operation  may  promise  fair  success,  espe- 
cially in  the  non-amcebic  cases.   In  cases 
in   which   the   abscess   is  discharging 
through  the  lung  operation  should  be 
deferred  if  the  patient's  condition  is 
favorable,  as  some  recover  spontaneously. 
Direct  opening  of  abscess  of  the  liver 
with  the  knife  causes  no  danger  of  peri- 
tonitis if  done  antiseptically.    The  in- 
cision must  be  free  and  lead  directly  to 
the  abscess.    It  is  advisable  to  make  the 
opening  as  high  as  possible.   It  is  useless 
to  suture  the  liver  to  the  parietal  wound. 
Incision  must  be  made  early,  and  ex- 
ploratory punctures  are  indicated  as  soon 
as  pus  is  suspected.    Chauvel  (Archives 
Gen.  de  Med.,  Aug.,  '89). 

Two  cases  of  abscess  of  the  liver  impli- 
cating the  pleural  cavity.  Incision 
evacuated  two  quarts  of  fluid.  Two  large 
drainage-tubes  were  introduced,  the  cav- 
ity washed  out,  and  the  antiseptic  dress- 
ing applied.  The  patient  made  a  prompt 
recovery.  Cabot  (Boston  Med.  and  Surg. 
Jour.,  Jan.  9,  '90) . 

Following  conclusions  presented  in  re- 
gard to  hepatic  abscesses:  1.  Pyremic  ab- 
scesses do  not  call  for  surgical  inter- 
ference. 2.  The  same  observations  apply 
to  abscesses  resulting  from  suppurative 


LIVER,  DISEASES  OF  THE.    TUMORS.  SYMPTOMS. 


phlebitis  of  the  portal  vein.  3.  Multiple 
abscesses  associated  with  dysentery  or 
ulceration  of  the  bowels  are  very  unfavor- 
able for  surgical  treatment.  They  must, 
however,  be  opened  and  treated  on  the 
same  lines  as  the  single  or  tropical  ab- 
scess. 4.  Single  abscesses  of  the  liver 
must,  if  they  approach  the  surface,  be 
opened.  If  the  abscesses  have  burst  into 
the  lung,  pleura,  pericardium,  peritoneum, 
or  kidney,  and  the  position  of  the  abscess 
can  be  clearly  determined,  it  must  be 
opened  without  delay.  If  the  position  of 
an  abscess  be  only  suspected  and  the  pa- 
tient be  losing  ground,  the  liver  should  be 
punctured  in  the  most  likely  situations. 
5.  Hydatids  of  the  upper  and  back  part  of 
the  liver  are  to  be  treated  upon  the  same 
lines.  6.  Empyema,  pericarditis,  and 
peritonitis  caused  by  rupture  of  an  he- 
patic abscess  or  hydatid  must  be  promptly 
dealt  with  on  general  principles.  Codlee 
(Brit.  Med.  Jour.,  Jan.  11,  25,  '90). 

Only  2  per  cent,  of  liver-abscesses  open 
through  the  thoracic  walls.  Free  incision 
with  resection  of  a  rib  is  the  best  method 
of  treatment  in  these  cases,  and  secures 
the  promptest  recovery  Raimundo  (Rev. 
de  Ciencias  Med.,  Apr.  5,  '92). 

Case  of  liver-abscess  in  which  death 
resulted  from  failure  to  maintain  free 
drainage.  Neil  Macleod  (Brit.  Med. 
Jour.,  Apr.  30,  '92). 

Abscess  following  dysentery  should  al- 
ways be  opened  freely  as  soon  as  exist- 
ence has  been  determined.  Incision  eight 
to  ten  centimetres.  Curetting  continued 
with  a  long  curette,  employing  continu- 
ous irrigation  until  water  flows  out  clear. 
Haemorrhage  never  observed  in  forty 
cases  reported.  Fontan  (Gaz.  Hebdom. 
de  Med.  et  de  Chir.,  Aug.  25,  '95). 

Literature  of  '96-'97-'98. 

An  hepatic  abscess,  when  seated  in  the 
upper  and  back  part  of  the  right  lobe,  is 
best  treated  by  resection  of  a  portion  of 
the  ninth  or  tenth  rib,  and  transpleural 
laparotomy,  the  pleura  being  stitched  to 
the  diaphragm  in  the  absenee  of  adhe- 
sions. When  the  anterior  portion  of  the 
liver  is  involved,  the  abscess  should  be 
exposed  by  anterior  laparotomy,  the 
edges    of    the    external    wound  being 


stitched  to  the  surface  of  the  liver  if 
practicable. 

The  inner  surface  of  the  abscess-cavity 
should  not  be  scraped;  simple  injections 
after  incision  are  quite  sufficient  and  less 
dangerous.  Ricard  (Bull,  et  Mem.  de  la 
Soc.  de  Chir.,  1-2,  '96). 

Seven  consecutive  cases  of  hepatic  ab- 
scess successfully  treated  by  incision. 
Walter  Boyd  (Brit.  Med.  Jour.,  Aug.  21, 
'97). 

The  treatment  of  liver-abscess  should 
be  prompt,  bold,  and  radical.  No  meas- 
ure is  successful  which  fails  completely 
to  evacuate  the  abscess  and  allow  free 
drainage.  This  can  be  done  with  precision 
and  safety  only  by  incision.  The  line  of 
incision  is  to  be  determined  by  the  posi- 
tion of  the  abscess.  George  B.  Johnston 
(Med.  Record,  June  5,  '97). 

The  point  of  election  in  liver-abscess 
is  the  most  dependent  part  of  the  collec- 
tion, or  the  point  showing  a  tendency  to 
rupture.  In  absence  of  this  the  points 
of  election  are  just  below  the  ribs,  or  in 
the  seventh  intercostal  space  in  mid- 
axillary  line.  In  early  operations,  or  be- 
fore adhesions  have  formed,  it  is  ad- 
visable to  open  the  peritoneal  cavity  first, 
and  pack  it  off  by  gauze,  preliminary  to 
opening  the  abscess.  The  subsequent 
management  is  similar  to  that  of  ab- 
scesses in  general.  John  G.  Cecil  (Amer. 
Pract.  and  News,  Apr.  17,  '97). 

Tumors  of  the  Liver. 

Of  these,  secondary  carcinomata  are, 
by  far,  the  most  common.  Primary  car- 
cinoma, sarcoma,  angioma,  and  lym- 
phadenoma  also  occur.  Myxoma,  cysto- 
sarcoma,  and  fibroma  are  rare  forms. 
Cancer  of  the  liver  is  met  with  in  about 
3  per  cent,  of  deaths  from  all  causes, 
and  in  all  persons  affected  with  cancer 
the  liver  is  the  seat  in  50  per  cent,  of 
the  cases,  the  liver  being  third  in  order 
of  frequency  of  internal  cancer. 

Symptoms. — In  many,  perhaps  half,  of 
the  cases  of  cancerous  disease  of  the  liver 
there  are  no  symptoms  by  which  the  dis- 
ease can  be  recognized  during  life.  The 
symptoms  of  the  primary  growth  usually 


LIVER,  DISEASES  OF  THE.    TUMORS.  SYMPTOMS. 


405 


overshadow  those  caused  by  the  liver  dis- 
ease. The  stomach  is  the  seat  of  the 
primary  growth  in  more  than  a  quarter 
of  all  cases;  so  that  symptoms  of  digest- 
ive disturbances  are  usually  prominent, 
such  as  loss  of  appetite,  distress  after 
food,  nausea,  and  vomiting.  Progressive 
loss  of  flesh  and  strength  is  an  early 
symptom.  Pain  and  uneasiness  in  the 
hepatic  region  are  common,  but  in  many 
cases  of  even  extensive  disease  of  the 
liver  neither  is  present.  No  doubt  both 
are  often  due  to  local  peritonitis. 

In  tumors,  especially  cancers,  which 
have  developed  at  the  hilus  or  under  the 
left  lobe,  an  arterial  murmur  can  be 
heard  all  over  the  organ,  due  to  stenosis 
of  the  hepatic  artery  or  to  compression 
of  the  abdominal  aorta.  Rovighi 
(Oesterr-ungar.  Centralb.  f.  d.  med.  Wis- 
sen.,  June  7,  '90). 

Case  of  primary  hepatic  cancer  in 
which,  during  life,  no  symptom  of  insuffi- 
ciency of  the  liver-functions  had  been  ob- 
served.  Pauly  (Lyon  Med.,  July  15,  '94). 

Literature  of  '96-'97-'98. 

Progressive  enlargement  in  malignant 
disease  is  almost  invariable.  When  ir- 
regular, the  growth  is  generally  second- 
ary. Tenderness  and  pain  is  usually 
experienced.  When  the  growth  is  deep- 
seated,  pain  may  be  but  little  marked  or 
absent.  Outlying  secondary  growths 
may  form  on  the  falciform  ligament. 
Gastric  derangements  are  frequent. 
Haemorrhages  into  the  skin  may  occur 
with  or  without  jaundice.  Jaundice  and 
ascites  are  accidental  symptoms.  They 
both  occur  in  about  half  the  cases.  In 
rare  cases  the  ascitic  fluid  may  be 
chylous.  Emaciation  of  a  steadily  pro- 
gressive type  is  most  characteristic. 
Death  often  occurs  within  three  months 
of  the  onset  of  symptoms.  Cachexia  is 
an  important  diagnostic  sign. 

Primary  malignant  disease  of  the  liver 
seems  to  be  more  frequent  in  men  than 
in  women.  Secondary  growl  lis  are 
usually  carcinomatous.  H.  D.  Rolleston 
(Clin.  Jour.,  Mar.  3,  '97). 


The  liver  is  usually  enlarged.  Hepatic 
dullness  may  extend  upward  to  the  fifth 
rib  in  the  midaxillary  line,  to  the  left 
as  far  as  the  spleen,  and  the  lower  edge 
may  be  felt  at  or  below  the  umbilicus. 
The  lower  edge  and  anterior  surface  be- 
low the  costal  margin  are  hard  and  often 
uneven  on  account  of  the  nodular  de- 
posits. The  nodules  in  some  cases  are 
felt  to  be  umbilicated:  an  absolutely 
diagnostic  sign.  In  cases  of  diffuse  in- 
filtration the  liver  may  be  very  large; 
occasional  instances  are  met  with  in 
which  it  is  smaller  than  normal.  The 
surface  is  smooth  and  hard  and  usually 
tender. 

Jaundice  is  present  in  about  half  the 
cases.   It  is  usually  slight  at  first,  becom- 
ing deeper  toward  the  end.    It  is  usu- 
ally due  to  pressure  on  the  common  bile- 
duct  in  the  transverse  fissure  by  carci- 
nomatous glands;  it  may  be  due  to  press- 
ure on  the  branches  in  the  liver  by  grow- 
ing nodules,  or  if  the  primary  growth  is 
in  the  head  of  the  pancreas  it  may  press 
on  the  common  bile-duct.  It  is  important 
to  remember  that  cancer  of  the  liver  is 
the  most  frequent  cause  of  long-standing 
jaundice;  it  is  permanent,  and  in  the 
later  stages  may  become  extremely  deep. 
Case  of  cancer  in  which  detached  por- 
tion caused  symptoms  of  lithiasis;  ob- 
struction   caused   jaundice;     glands  of 
hilum  gave  rise  to  circulatory  symptoms, 
while  consecutive  cirrhosis  further  com- 
plicated the  case.    Gilbert,  Claude  (Ar- 
chives Gen.  de  MeU,  May,  '95). 

Ascites  occurs  in  some  cases,  and  is 
caused  by  pressure  on  the  portal  vein  or 
to  extension  of  the  cancer  to  the  peri- 
toneum. It  is  present  in  the  cirrhotic 
form  of  cancer. 

The  superficial  veins  are  enlarged. 
Some  fever  is  not  rare,  continued  or  in- 
termittent, especially  when  the  disease 
runs  a  rapid  course.  It  may  occur  in 
simple  cancer,  or  may  indicate  suppura- 


406 


LIVER,  DISEASES  OF  THE.    TUMORS.  DIAGNOSIS. 


tion.  Haemorrhages  into  the  skin  or 
from  the  mucous  surfaces  may  occur  late 
in  the  disease. 

Course  and  Duration. — Death  usually 
results  within  a  few  months;  it  is  rarely 
delayed  beyond  a  year  after  the  symp- 
toms have  declared  themselves.  Occa- 
sionally the  progress  is  delayed  for  some 
weeks  at  a  time,  during  which  some  im- 
provement may  take  place  in  the  general 
condition.  Death  is  usually  due  to 
progressive  debility,  with,  in  the  last 
stage,  some  infection  that  closes  the 
scene. 

Case  in  which  cancer  developed  with 
great  rapidity,  causing  death  ninety  days 
after  initial  symptom.  Bonnevie  (Norsk 
Mag.  f.  Lsegevid.,  p.  127,  '95). 

Diagnosis.  —  The  occurrence  of  pro- 
gressive loss  of  flesh  and  strength,  of  pain 
and  tenderness  in  the  hepatic  region, 
and  of  rapid  enlargement  of  the  liver, 
with  the  formation  of  nodules,  forms  a 
fairly  sure  basis  for  diagnosis.  Even 
with  this  symptom-group,  difficulties 
may  beset  us. 

Case  in  which  cancer  was  only  recog- 
nized post-mortem,  owing  to  absence  of 
all  usual  symptoms.  Dupont  (Archives 
Med.  Beiges,  Sept.,  '95). 

Certain  cases  of  hepatic  cancer  closely 
resemble  terminal  stages  of  heart  disease. 
But  in  latter  slighter  diminution  of  urea 
and  albuminuria  present,  whereas  absent 
in  cancer,  ■ —  main  differential  points. 
Hanot,  Flu  (Jour,  de  Med.  et  de  Chir. 
Prat.,  Aug.  16,  '95). 

Apparent  enlargement  of  the  liver 
may  be  due  to  hardened  faeces  in  the 
transverse  colon,  which  is  tender,  owing 
to  the  enteritis  caused  by  the  hard 
masses.  Indurated  puckered  omentum 
and  tumors  of  the  stomach,  kidney,  and 
the  abdominal  wall  may  also  simulate  a 
large  liver.  The  large  cirrhotic  liver 
may,  in  the  early  stage,  be  mistaken  for 
cancer,  as  the  liver  is  large  and  the  jaun- 
dice usually  well  marked;  but  the  liver 


is  smooth  and  not  tender  and  there  is 
absence  of  the  cachexia  of  cancer.  The 
spleen  is  also  large. 

Case  diagnosticated  as  Hypertrophic 
cirrhosis  of  the  liver,  which  proved  at 
the  autopsy  to  be  a  case  of  cancer  of  the 
omentum  and  of  the  liver.  Watkins 
(Jour.  State  Med.  Soc.  of  Ark.,  July  15, 
'91). 

S}rphilitic  disease  in  which  there  is 
large  amyloid  liver  with  gummatous 
nodules  may  present  some  difficulties,  as 
may  also  echinococcic  liver  with  large 
cysts.  In  both,  the  history  is  more  pro- 
longed and  there  is  absence  of  cachexia 
and  usually  of  jaundice.  Ascites  is 
strongly  indicative  of  cancer.  The  early 
period  of  cancer  with  cirrhosis  may  be 
indistinguishable  from  atrophic  cirrho- 
sis; there  is  similar  jaundice  and  ascites 
in  both,  but  later  the  cachexk  is  more 
marked  in  the  cancerous  form. 

Melanosarcoma  usually  involves  other 
organs  as  well.  It  may  cause  great  en- 
largement of  the  liver.  Secondary 
tumors  may  form  in  the  skin.  In  many 
cases  there  is  melanuria:  a  characteristic 
symptom.  Great  difficulty  is  often  ex- 
perienced in  differentiating  cancer  of 
neighboring  organs  from  cancer  of  the 
liver,  especially  if  they  are  adherent  to 
the  liver. 

Literature  of  '96-'97-'98. 

The  chief  interest  in  tongue-like  acces- 
sory lobes  of  the  liver  is  in  connection 
with  the  diagnosis  of  abdominal  tumors. 
Unless  fully  alive  to  the  great  variety,  a? 
to  shape  and  position,  in  which  the  ac- 
cessory lobes  of  the  liver  may  present 
themselves,  one  will  often  be  misled. 
McPhedran  (Canadian  Pract..  June,  '9G). 

in  all  cases  of  doubt  in  neoplasms  of 
the  liver,  it  is  advised  to  explore  the 
hilum  of  the  liver  to  see  if  there  are  any 
enlarged  glands  present:  if  present,  they 
show  a  metastasis  from  a  malignant 
growth,  and  puncture  is  unnecessary: 
but  their  absence  does  not  exclude  a 


LIVER,  DISEASES  OF  THE.  TUMORS. 


ETIOLOGY.    MORBID  AXATOMY. 


407 


malignant  growth,  for  if  it  is  a  second- 
ary growth  the  metastasis  would  not  be 
through  the  lymphatics,  but  through  the 
•  venous  channels,  and  the  glands  would 
not  be  enlarged.  Primary  cancer  of  the 
liver  shows  metastasis  in  the  glands  situ- 
ated at  the  hilum.  Tuffier  (Gaz.  Hebd. 
de  Med.  et  de  Chir.,  Jan.  28,  '97). 

A  very  handy  and  accurate  method  of 
recording  the  size  and  position  of  ab- 
dominal organs  or  tumors  has  been  called 
the  Keith  method.  It  consists  in  first 
carefully  percussing  out  the  organ, — say, 
the  liver.  The  limits  of  percussion-dull- 
ness are  then  marked  on  the  skin  by 
black  paint  (Indian  ink).  Then  with 
red  paint  the  ribs  are  mapped  out  by  a 
broad  band  drawn  on  the  skin  over  each 
rib.  When  the  coloring  fluids  have  dried, 
a  piece  of  thin,  transparent  muslin  is 
placed  over  the  front  of  the  body,  large 
enough  to  cover  the  body  from  the  clavi- 
cles to  the  pubes.  With  red  paint  the 
red  lines  over  the  ribs,  the  arch  of  the 
subcostal  angle,  the  nipples,  and  the  um- 
bilicus are  then  traced  on  the  muslin, 
and  finally  the  brush  is  drawn  along  the 
black  outlines  of  the  liver  as  they  are 
seen  through  the  muslin.  On  the  muslin 
the  patient's  name  and  the  date  of  draw- 
ing, as  well  as  the  disease  should  be 
painted  for  future  reference  and  compari- 
son with  note-book.  By  this  method  one 
preserves  a  life-sized  drawing  of  the  liver, 
and  a  permanent  record.  James  Cantlie 
(Clin.  Record,  June  22,  '98). 

Etiology. — Cancer  of  the  liver  is  most 
frequently  secondary  to  cancerous  dis- 
ease in  the  organs  connected  with  the 
portal  circulations.  Hence  it  occurs 
secondarily  to  cancer  of  the  stomach, 
rectum,  colon,  oesophagus,  gall-bladder, 
bile-ducts,  and  pancreas.  It  also  follows 
cancer  of  the  uterus  and  ovaries  and  the 
mammary  gland. 

It  occurs  usually  in  late  adult  life, 
especially  between  the  fortieth  and  six- 
tieth years,  but  may  occur  in  children. 
The  relative  frequency  of  its  occurrence 
in  the  sexes  is  doubtful;  some  observers 
state  that  it  is  more  frequent  in  males, 
others  in  females.    My  own  experience 


|  coincides  with  the  former.  Inquiry  is 
a  doubtful  cause  and  cancer  of  the  bile- 

|  ducts  is  frequently  associated  with  gall- 

j  stones,  but  whether  as  a  cause  or  a  result 

!  is  uncertain. 

Morbid  Anatomy.  —  As  the  primary 

|  growth  is  situated  in  some  organ  whose 
blood  is  carried  to  the  liver  by  the  portal 
vein,  the  liver  becomes  early  affected, 
and  often  is  the  seat  of  large  deposits 
at  the  time  of  death.  The  deposits  are 
in  the  form  of  whitish  nodules  scattered 
irregularly  throughout  the  liver  just  as 
we  would  expect,  in  view  of  infection 
through  the  blood  of  the  portal  vein. 
The  nodules  vary  in  size  from  a  micro- 
scopical point  up  to  a  mass  occupying  a 
large  portion  of  the  organ.  As  they 
grow  in  the  direction  of  least  resistance 
they  appear  early  beneath  the  capsule, 
and  if  the  abdominal  wall  is  thin  they 
may  be  felt  and  even  seen  through  it. 
They  may  be  firm  from  fibrosis  or  soft 
from  degeneration;  the  former  shows 
umbilication  on  the  surface,  owing  to 
contraction  of  the  fibrous  tissue.  The 
masses  are  globular,  but  coalescence  may 
result  in  the  formation  of  large  irregular 
masses  presenting,  on  section,  a  striking 
contrast  to  the  liver-tissue.  Their  color 
may  be  a  bright  yellow,  from  bile-stain- 
ing; dark-red,  due  to  haemorrhage;  or 
pale  yellow,  from  fatty  degeneration. 

The  secondary  cancers  are  of  the  same 
structure  as  the  primary  one  from  which 
the  infection  was  derived:  usually  alveo- 
lar or  c}rlindrical  carcinoma.  The  peri- 
toneum over  them  may  be  thickened 
and  strong  adhesions  formed  with  the 
abdominal  wall  or  diaphragm.  Usually 
some  of  the  bile-ducts  are  compressed, 
obstructing  the  flow  of  bile. 

Primary  Cancer  of  the  Liver. — 
Of  this  there  are  three  forms: — 

(a)  A  simple  large  tumor  with  well- 
defined  boundaries.   It  is  usually  grayish 


LIVER,  DISEASES  OF  THE.    TUMORS.    MORBID  ANATOMY. 


408 

white,  but  may  be  the  seat  of  haemor- 
rhage. 

(b)  Nodular  growths  are  the  most  com- 
mon, and  the  whole  liver  resembles  the 
appearance  it  presents  when  it  is  the  seat 
of  secondary  carcinoma. 

(c)  Cancer  with  Cirrhosis.' — This  is  a 
remarkably  rare  form.  In  it  the  cancer- 
cells  are  uniformly  diffused  through  the 
liver;  so  that  the  fibrous  tissue  is  in- 
creased in  all  directions.  This  may  con- 
tract and  cause  the  liver,  which  at  first 
is  enlarged,  to  become  smaller  than  nor- 
mal. The  organ  looks  like  a  coarse  cir- 
rhosis. When  cut  there  are  wide  white 
bands  seen  running  through  the  organ, 
the  gland-tissue  between  them  having 
vanished.  Secondary  growths  in  other 
parts  of  the  body  scarcely  ever  occur. 

Out  of  258  cases  recorded  in  the  Berlin 
Pathological  Institute  from  1880  to  1889, 
only  6  cases  of  true  primary  cancer  of  the 
liver  found,  and  of  these  2  are  doubtful. 
Hansemann  (Berliner  klin.  Woch.,  Apr. 
21,  '90). 

Sequence  of  events  in  cases  of  cirrhotic 
cancer  held  to  be  as  follows:  1.  Cirrhosis 
with  hyperplasia  of  the  liver-cells.  2.  The 
embryonal  connective  tissue  gradually 
becomes  fibrous  and  the  liver-cells  are 
converted  into  cancer-cells.  Fussell  and 
Kelly  (Univ.  Med.  Mag.,  Aug.,  '95). 

Cirrhotic  cancer  arises  from  an  hyper- 
plasia of  the  hepatic  epithelium  inde- 
pendent of  the  cirrhosis,  although  the 
latter  may  favor  the  development  of  the 
carcinoma.  Siegenbeck  Van  Heukelom 
(Ziegler's  Beitriige,  B.  16,  H.  3). 

In  cirrhotic  cancer  cirrhosis  looked 
upon  as  secondary  and  as  a  defence  of  the 
organism  against  the  cancer.  Notthafft 
(Deut.  Arch.  f.  klin.  Med.,  Aug.  29,  '95). 

Literature  of  '96-'97-'98. 

Case  of  primary  cancer  of  the  liver  with 
secondary  cancer  of  the  stomach,  peri- 
portal glands,  pancreas,  and  vena  cava. 
The  mass  occupied  nearly  the  entire  right 
lobe  of  the  liver.  At  no  place  was  it 
covered  by  more  than  two  centimetres  of 


liver-tissue.  Martin  and  Hamilton  (Mon- 
treal Med.  Jour.,  Apr.,  '96). 

Primary  carcinoma  may  be:  1.  Mas- 
sive, more  often  found  in  the  right  lobe, 
where  the  liver  is  expanded  like  a  shell 
around  the  growth.  2.  Infiltrating,  the 
growth  being  diffuse,  of  comparatively 
slow  growth,  and  so  hard  as  to  simulate 
cirrhosis.  3.  Nodular,  when  the  appear- 
ance is  similar  to  that  due  to  secondary 
growths.  4.  Carcinoma  with  cirrhosis. 
H.  D.  Rolleston  (Clin.  Jour.,  Mar.  3,  '97). 

Sarcoma. — Two  forms  occur:  primary 
and  secondary.  The  primary  cannot  be 
distinguished  at  the  bed-side  from  car- 
cinoma, and  even  after  death  it  is  often 
difficult  to  differentiate  them.  The  dis- 
ease is  extremely  rare. 

In  case  of  primary  sarcoma  of  the  liver 
in  a  child  4  months  old  there  was  no 
icterus,  but  the  abdomen  was  enormously 
distended.  At  the  necropsy  the  liver  was 
found  to  contain  numerous  disseminated 
tumors  of  a  light  red-brown.  The  growth 
consisted  of-  small  round-cells,  which 
seemed  to  originate  from  the  endothelium 
of  the  interacinous  blood-vessels  and 
penetrate  into  the  veins,  where  they  com- 
pressed the  liver-cells.  Lendrop  (Hosp.- 
tid.,  p.  217,  '93). 

Literature  of  '96-'97-'98. 

Case  of  primary  sarcoma  of  the  liver. 
Increase  in  the  size  of  the  abdomen  con- 
tinued for  three  months  without  symp- 
toms, when  faeces  became  black  and  the 
urine  dark.  Later  the  abdomen  increased 
still  further  in  size  and  nodules  could  be 
felt.  He  had  anasarca  downward  from 
the  eighth  rib  and  marked  ascites.  The 
skin  showed  slight  icteroid  discoloration, 
the  thorax  was  negative,  the  abdomen 
was  enormously  distended,  and  hepatic 
dullness  commenced  at  upper  border  of 
fifth  rib;  lower  edge  of  the  liver  was 
irregular  and  could  be  felt  in  the  neigh- 
borhood of  the  umbilicus.  Death  oc- 
curred as  a  result  of  oedema  of  the  lungs. 
C.  von  Kahlden  (Ziegler's  Beit  rage,  vol. 
xxi,  H.  2,  '97). 

Secondary  sarcomas  of  the  liver  ex- 
I  actly  reproduce  the  form  of  the  original 


LIVER,  DISEASES  OF  THE.    TUMORS.  TREATMENT. 


409 


growth.  The  patient  usually  dies  before 
any  symptoms  are  produced  by  them. 
Melanosarcoma  is  the  most  important 
form;  it  develops  in  the  liver  secondarily 
to  sarcoma  of  the  eye  or  of  the  skin.  It 
is  very  rarely  primary.  The  liver  is 
greatly  enlarged,  and  is  affected  by  uni- 
form infiltration  or  by  nodular  black 
masses.  In  the  former  case  the  cut  sur- 
face is  studded  with  black  or  brown  gran- 
ules. There  are  usually  metastases,  af- 
fecting in  some  cases  every  organ  in  the 
body.  Nodules  of  melanosarcoma  in  the 
skin  may  guide  to  the  diagnosis.  (Osier.) 

[Melanuria  seems  to  be  so  nearly  con- 
stant a  symptom  of  melanosarcoma  as  to 
be  of  considerable  value  in  the  diagnosis 
of  obscure  cases.  There  is  good  reason 
to  believe  that  it  only  appears  when  me- 
tastases have  occurred  in  the  internal 
organs,  especially  the  liver.  It  is  not, 
however,  pathognomonic.  F.  C.  Shat- 
tuck,  Assoc.  Ed.,  Annual,  '90.] 

Case  of  melanotic  sarcoma  in  which 
liver  weighed  13  pounds  10  ounces.  Codd 
(Birmingham  Med.  Rev.,  June,  '95). 

Case  in  which  there  was  a  large  liver 
with  pain  in  the  abdomen  and  delirium. 
The  urine  was  dark  red  in  color  and  on 
standing  became  darker.  It  contained 
some  sugar,  and  upon  the  addition  of 
Fe2Cl8  became  black.  There  was  some 
leucocytosis  containing  pigment,  and 
there  was  also  some  free  pigment  in  the 
blood.  Diagnosis  of  melanotic  sarcoma 
of  the  liver  confirmed  by  autopsy.  Pick- 
ler  (Zeit.  f.  Heilk.,  B.  17,  H.  2,  3). 

Literature  of  '96-'97-'98. 

Liver-sarcoma  tends  to  assume  an  alve- 
olar arrangement.  Kahlden  (Beit.  z. 
path.  Anat.  u.  z.  Path.,  B.  20,  H.  2,  Jena, 
'97). 

Other  Forms  of  Hepatic  Tumor. — 
Cavernous  angioma  are  common,  but 
produce  no  symptoms  during  life.  They 
occur  as  small,  reddish  bodies,  and  con-  | 
sist  of  dilated  blood-vessels.    They  have 


produced  large  tumors  in  children  occa- 
sionally. 

In  man  the  liver  is,  perhaps,  the  most 
frequent  seat  of  angiomata.  Adami 
(Montreal  Med.  Jour.,  July,  '94). 

Adenomata  observed:  1.  Post-mortem, 
in  subjects  affected  with  atrophic  cir- 
rhosis or  rarer  disease.  2.  In  subjects 
presenting  a  cirrhosis  of  extremely-rapid 
progress,  persistent  icterus  and  enlarge- 
ment of  the  liver  being  added  to  the  ordi- 
nary symptoms.  3.  In  cases  the  symp- 
toms of  which  do  not  resemble  those  of 
cirrhosis,  but  of  neoplasm.  Darier  (Bull, 
de  la  Soc.  Anat.,  No.  12,  '92). 

Case  of  Laennec's  atrophic  cirrhosis  of 
rapid  development  accompanied  with 
icterus  and  associated  with  adenoma  of 
the  liver,  occurring  in  a  male.  There  was 
extensive  oedema  and  ascites.  The  spleen 
was  enlarged  and  diffluent,  the  kidneys 
enlarged  and  congested.  Dufournier 
(Bull,  de  la  Soc.  Anat.,  No.  21,  '92). 

Case  of  tubular  adenoma  of  the  liver  in 
a  man  aged  60  years.  Death  occurred 
from  rupture  of  the  liver.  Vanni  (Ri- 
vista  Clinica  e  Terap.,  Apr.,  '93). 

Treatment. — As  cancer  of  the  liver  is 
invariably  fatal,  nothing  can  be  done 
beyond  allaying  the  pain,  relieving  the 
gastric  disturbance,  removing  ascitic 
fluids  if  excessive,  etc. 

In  animals  one-third  of  the  liver  may 
be  removed  without  causing  death. 
Ceccberelli  (Wiener  med.  Presse,  May  26, 
'89). 

Removal  of  the  liver  in  the  frog  does 
not  involve  an  immediately  fatal  tissue, 
as  in  the  case  in  mammals.  Roger  (La 
Sem.  Med.,  June  15,  '92). 

Liver-haemorrhage  is  amenable  to  press- 
ure applied  directly  upon  the  bleeding 
surface,  in  that  regard  resembling  the 
kidney.  L.  McLane  Tiffany  (Amer. 
Jour.  Med.  Sci.,  June,  '88). 

Large  portions  of  the  liver  can  be  re- 
moved without  undue  disturbance  of  the 
function  of  that  organ;  the  escape  of  bile 
into  the  peritoneal  cavity  is  not  a  usual 
phenomenon  after  such  an  operation,  and 
it  may  be  generally  prevented  either  by 
searing  the  raw  surface  of  the  liver,  by 


LIVER,  DISEASES  OF  THE. 


TUMORS.  TREATMENT. 


ligation,  or  by  securing  the  stump  in  the 
abdominal  wound,  and  even  if  the  bile 
does  enter  the  peritoneal  cavity  the  re- 
sult is  not  necessarily  fatal ;  haemorrhage 
need  not  be  greatly  feared,  as  vessels  can 
often  be  tied  separately  or  en  masse,  cut 
through  by  the  cautery,  or  controlled  by 
pressure;  resection  or  amputation  is  best 
done  either  by  enucleation,  by  the  cau- 
tery, or  with  the  knife  or  scissors, — pref- 
erably, perhaps,  in  the  order  named;  the 
mortality  thus  far  has  only  been  about 
10  per  cent.  W.  W.  Keen  (Boston  Med. 
and  Surg.  Jour.,  Apr.  28,  '92). 

Portions  of  the  liver  removed  by  opera- 
tion speedily  replaced  and  parts  renewed 
perform  their  function  normally;  sur- 
geon justified  in  removing,  when  neces- 
sary, even  large  portions.  Von  Berg- 
mann  (Archiv  f.  klin.  Chir.,  B.  46,  H.  2, 
'95). 

Case  of  successful  removal  of  an  ade- 
noma connected  by  a  thick  pedicle  with 
the  lower  surface  of  the  liver.  Von 
Bergmann  (Brit.  Med.  Jour.,  May  27, 
'93). 

Literature  of  '96-'97-'98. 

Haemorrhage  forms  the  serious  danger 
which  makes  the  extirpation  of  malig- 
nant tumors  of  the  liver  very  perilous. 
Routier  (Univ.  Med.  Jour.,  Feb.,  '97). 

As  a  means  of  haemostasis,  the  tempo- 
rary digital  compression  of  the  pedicle  of 
the  liver  is  proposed.  The  method  of 
procedure  is  as  follows:  The  left  index 
finger  is  introduced  through  the  foramen 
of  Winslow  and  compression  by  the 
thumb  of  all  the  structures  of  the  pedicle. 
Turner  (Gaz.  Hebdom.  de  Med.  et  de 
Chir.,  Jan.  28,  '97). 

In  operations  on  the  liver  ligature  of 
the  mass  of  the  liver,  slowly  and  firmly 
drawn  tight,  closes  the  lumen  of  the 
vessels  and  thus  prevents  haemorrhage. 
After  chloroform  the  peritoneum  is 
opened  and  the  lobe  of  the  liver  drawn 
out  through  the  wound.  A  row  of  liga- 
tures is  then  made  through  the  liver  with 
a  blunt  needle  and  a  double  silk  thread, 
the  entire  length  of  the  piece  to  be  re- 
moved. The  needle  is  passed  through  the 
substance  of  the  liver  several  times,  a 
few  centimetres  apart.  The  nearest 
threads  in  the  different  holes  are  tied  to- 
gether.   When  these  ligatures  are  drawn 


tight,  the  piece  to  be  resected  in  front  or 
back  of  them  is  removed.  Compresses  of 
gauze  should  be  applied  to  control 
haemorrhage  of  the  parenchyma.  After 
ablation  the  hepatic  stump  is  sutured  to 
the  end  of  the  abdominal  wound,  or  the 
great  omentum  can  be  sutured  to  the 
cut  surface  of  the  liver,  or  the  stump  can 
be  put  back  into  the  abdominal  cavity 
and  the  walls  closed  with  a  suture  in 
three  stages,  after  dressing  with  collodion 
gauze. 

The  most  convenient  cutaneous  incision 
is  parallel  to  the  arch  of  the  false  ribs, 
one  or  two  finger-breadths  below,  ten 
to  fifteen  centimetres  in  length,  starting 
at  the  right  parasternal  line  for  the  right 
lobe,  and  at  the  median  line,  swerving 
to  the  left,  for  the  left  lobe.  Kousnetzoff 
and  Pensky  (Rev.  de  Chir.,  Dec,  '96). 

The  best  procedure  in  treating  liver- 
wounds  after  removal  of  tumors  is  to  use 
a  rubber  tube  for  a  tourniquet,  if  neces- 
sary to  tie  all  large  vessels  separately, 
using  pressure  for  the  oozing:  to  close 
the  liver  as  much  as  possible  with 
sutures;  to  drop  the  stump  and  to  sur- 
round it  completely  with  sterile  gauze, 
packing  iodoform  gauze  against  the  liver- 
wounds,  and  leave  the  abdominal  wound 
sufficiently  open  to  facilitate  dressing  the 
liver-wound.  Elliott  (Annals  of  Surg., 
July,  '97). 

In  resection  of  the  liver  it  is  recom- 
mended to  apply  to  the  liver  around  the 
portion  to  be  removed  a  series  of  inter- 
locked ligatures  of  thick  silk.  Each  in- 
dividual ligature,  after  being  crossed 
with  its  fellow  to  the  right  and  left,  is 
slowly  and  steadily  tied  with  such  firm- 
ness that  the  liver-parenchyma  is  cut, 
but  the  vessels  are  retained  undivided  in 
the  loop.  "When  the  whole  series  of  liga- 
tures are  tied  then  the  vessels  are  to  be 
severed  by  the  knife  or  scissors.  It  is  of 
importance  while  transfixing  the  liver  to 
use  little  force,  and  Avhen  any  slight  ob- 
stacle to  the  passage  of  the  instrument 
is  encountered,  to  manipulate  the  needle 
from  side  to  side,  and  so  gently  guide  it 
past  the  obstruction. 

The  points  of  transfixion  ought  to  be 
about  one  centimetre  apart.  In  experi- 
ments on  dogs  no  difficulty  has  ever  been 
met  with,  and  the  wound  in  the  liver  has 


LIVER,  DISEASES  OF  THE.    HYDATID  CYST. 


411 


never  bled  in  the  slightest  degree,  either 
primarily  or  secondarily. 

It  might  be  well  in  excising  portions 
of  the  liver  to  make  the  wound  wedge- 
shaped,  so  that,  hsemostasis  having  been 
obtained  by  ligatures,  the  wound  might 
be  made  less  extensive  by  means  of 
sutures  passed  from  side  to  side.  M. 
Auvray  (Revue  de  Chir.,  Apr.,  '97). 

Successful  removal  of  an  angioma  of 
the  liver  by  elastic  constriction  external 
to  the  abdominal  cavity.  W.  W.  Keen 
(Penna.  Med.  Jour.,  Oct.,  '97). 

Successful  extirpation  of  a  large  caver- 
nous angioma  of  the  liver.  Its  origin 
was  from  the  lower  surface  of  the  left 
lobe  by  a  broad  attachment.  Pfannen- 
stiel  (Allg.  Med.  Central-Zeit.,  Feb.  19, 
'98). 

Case  in  which  left  lobe  of  the  liver  con- 
tained a  growth.  A  double  temporary 
ligature  of  catgut  was  put  around  the 
portion  of  the  liver  to  be  resected.  Then, 
while  strong  traction  was  made,  a  ten- 
tative cut  was  made  in  the  liver.  The 
vessels  were  drawn  and  ligated  as  the 
resection  proceeded.  A  large  piece  of  the 
liver  was  thus  resected  without  any 
haemorrhage.  A  large  piece  of  sterilized 
rubber  tissue  was  placed  on  the  intestines 
and  a  piece  of  gauze  against  the  raw  sur- 
face of  the  liver.  These  were  removed 
in  a  few  days.  The  patient's  general 
condition  improved  markedly.  H.  Lilien- 
thal  (Med.  Record,  Oct.  22,  '98). 

Successful  removal  of  an  epithelial 
tumor  from  the  middle  of  the  anterior 
border  of  the  liver.  Use  was  made  of 
the  method  advocated  by  Kousnetzoff  and 
Pensky,  consisting  of  a  system  of  chain 
ligatures,  the  tissue  of  the  liver  being 
divided  with  a  thermocautery.  Haemor- 
rhage was  in  this  way  almost  entirely 
avoided.  The  abdominal  wound  was  left 
open  and  it  rapidly  graduated.  Terrier 
(Med.  News,  Jan.  15,  '98). 

Hydatid  Cyst  of  the  Liver. 

Symptoms.  —  Small  cysts  cause  no 
symptoms;  they  may  be  discovered  at 
the  autopsy.  Cysts  may  reach  consider- 
able size  without  causing  inconvenience 
and  be  discovered  as  a  tumor-like  en- 
largement accidentally.    The  liver  en- 


larges irregularly  and  in  time  the  cyst 
causes  disturbance  by  pressing  on  some 
neighboring  organ  or  part,  interfering 
with  its  function.  If  in  the  dome  of 
the  liver  it  may  displace  the  heart  or 
lungs.  It  may  press  on  the  bile-passages, 
jaundice  resulting;  or  on  the  portal  vein, 
causing  ascites.  If  it  presses  on  the  vena 
cava  it  causes  oedema  of  the  legs.  If 
superficial,  the  cyst  may  fluctuate  to 
palpation,  or,  if  tense,  it  may  be  felt  as 
a  hard  solid  mass.  Hydatid  thrill  is 
sometimes  obtained  by  placing  one  hand 
lightly  on  the  cyst  and  tapping  it  gently 
with,  the  fingers  of  the  other  hand.  The 
thrill  has  been  ascribed  to  the  sudden 
impact  of  the  daughter-cysts  against 
each  other  and  against  the  wall  of  the 
cyst;  but  thrill  is  sometimes  obtained 
in  cysts  which  contain  only  clear  fluid. 

Rupture  of  the  cyst  may  occur.  If 
it  takes  place  into  any  of  the  serous  cavi- 
ties inflammation  results.  The  pleura 
suffers  most  frequently;  perforation  of 
the  lung  often  follows,  with  pneumonia 
and  the  expectoration  of  cysts  and  hook- 
lets.  More  often  pus,  blood,  and  bile- 
pigment  are  coughed  up,  such  as  occurs 
in  gangrene  or  abscess  of  'the  lung  sec- 
ondary to  liver-abscess. 

The  cyst  may  rupture  into  the  stom- 
ach, as  proved  by  the  vomiting  of  cysts 
and  hooklets;  or  into  the  intestine,  with 
the  appearance  of  these  bodies  in  the 
faeces,  as  would  occur  also  if  rupture 
takes  place  into  the  bile-passages.  Eupt- 
ure  may  occur  into  the  pelvis  of  the  right 
kidney  followed  by  the  presence  of  the 
hooklets  and  cysts  in  the  urine. 

Cases  of  hydatid  cysts  in  which  cyst 
opened  through  gall-bladder.  Brjucha- 
now  (Bolnit.  Gaz.  Botkina,  No.  2.  '95)  : 
Medwedjewa  (Bolnit.  Gaz.  Botkina.  No. 
2,  '95).  ' 

Case  of  hydatid  cysts  in  which  cyst 
opened  into  bladder.  Henczynski 
(Munch,  med.  Woch.,  Mar.  26,  '95).  , 


412 


LIVER,  DISEASES  OF  THE.    HYDATID  CYST.  DIAGNOSIS. 


Case  of  hydatid  disease  of  the  liver, 
with  perforation  of  one  of  the  cysts  into 
the  stomach.  Karmilow  (Laitopisj  Chir. 
kago  obschtschestwa,  No.  3,  '92). 

Hooklets  are  frequently  absent  from 
hydatid  tumors.  James  Watson  (Lancet, 
Dec.  3,  '92). 

Case  of  cyst  in  the  liver  containing  10 
quarts  of  liquid.  Microscope  showed  no 
traces  of  echinococcus  and  no  bile-salts  or 
pigment.  There  was  no  epithelial  lining 
of  the  cyst.  Boyer  (Amer.  Jour.  Med. 
Sci.,  May,  '93). 

Literature  of  '96-'97-'98. 

Case  of  ileus  due  to  hydatid  cyst  of 
the  liver.  Reichold  (Munch,  med.  Woch., 
Apr.  27,  '97). 

Apart  from  such  accidents,  the  symp- 
toms may  consist  only  of  trifling  dis- 
comfort in  the  hepatic  region. 

Eupture  of  the  cyst  is  often  followed 
by  severe  urticaria;  it  has  been  attrib- 
uted to  a  toxic  material  in  the  fluid.  It 
may  also  follow  aspiration  of  the-  cyst. 

Diagnosis. — This  is  rarely  possible  be- 
fore the  cyst  has  attained  considerable 
dimensions;  then  the  irregular  enlarge- 
ment of  the  liver  for  a  long  period,  with 
the  preservation  of  health,  indicates  hy- 
datid disease.  It  may  be  necessary  to 
aspirate  the  cyst,  and,  if  hooklets  are 
found  in  the  fluid,  the  diagnosis  is  con- 
firmed. A  fluctuating  tumor  in  the  epi- 
gastrium is  suggestive;  it  may  give 
fremitus  and  be  within  easy  reach  of  the 
aspirator-needle.  Abscess  of  the  liver  is 
differentiated  by  the  absence  of  symp- 
toms of  suppuration.  It  will  not  be 
possible  to  distinguish  a  suppurating  hy- 
datid cyst  unless  the  hooklets  be  found 
in  the  fluid.  Cancer  has  been  closely 
simulated  by  suppurating  cyst.  The 
clinical  history  usually  serves  to  differ- 
entiate it.  Dilated  gall-bladder  and  hy- 
dronephrosis  have  been  mistaken  for 
hydatid  cyst.  A  more  common  error 
is  the  mistaking  of  a  cyst  of  the  dome 


of  the  liver  for  right  pleural  effusion. 
Subdiaphragmatic  abscess,  and  purulent 
pleurisy  secondary  to  rupture  of  a  cyst 
are  conditions  difficult  or  impossible  to 
distinguish  unless  the  hooklets  are  found 
in  the  fluid. 

In  hydatid  cysts  of  the  liver  a  pre- 
liminary puncture  with  the  aspirator 
should  always  be  performed,  as  it  estab- 
lishes the  diagnosis  and  may  effect  a 
cure.  In  subdiaphragmatic  hepatic  cysts 
the  transpleural  incision  with  costal  re- 
section at  one  and  the  same  time  should 
be  the  operation  preferred.  Segond  (Lan- 
cet, Apr.  14,  '88). 

Peculiar  symptom  observed  in  two 
cases  of  hydatid  which  is  believed  to  be 
of  great  value  in  the  diagnosis  of  im- 
pending or  actual  perforation  of  the  cyst. 
It  is  a  highly  characteristic  aromatic 
odor,  resembling  that  of  boiled  plums. 
Eichhorst  (Zeits.  f.  klin.  Med.,.  B.  17, 
Supplement  H,  '90). 

Resounding  sign  described  by  Santini 
a  valuable  diagnostic  point.  Uniform  in 
single  cyst,  varying  when  a  number 
present.  Fiaschi  (Australasian  Med. 
Gaz.,  Aug.  20,  '95). 

A  new  physical  sign  for  hydatid  cysts 
consists  in  the  development  of  a  peculiar 
sound  on  combined  auscultation  and  per- 
cussion. Rovighi  (Policlinico,  Xo.  11, 
'94). 

Literature  of  'm-'dl-'dS. 

In  diagnosis  between  echinococcic  cyst 
of  the  liver  pointing  upward  and  pleurisy 
with  effusion  the  complete  absence  of  the 
breath-sounds  and  the  occurrence  of  pains 
beneath  the  shoulder-blade  are  signifi- 
cant points.  In  pleurisy  the  heart 
pushed  to  the  left,  in  hydatid  cysts  to 
the  left  and  upward.  Sometimes  an  elas- 
tic resistance  may  be  felt  and  fluctu- 
ation occasionally  occurs.  Cardarelli 
(Giorn.  Inter,  deile  Sci.  Med.,  Feb.  20, 
'96). 

The  term  hydatid  is  applied  to  the 
bladder-worms,  which  are  the  larval 
forms  of  the  Taenia  echinococcus  \  the 
minute  tape-worm  of  the  dog  family. 
When  fully  grown  the  parasite  is  not 


LIVER,  DISEASES  OF  THE.    HYDATID  CYST.    MORBID  ANATOMY. 


413 


more  than  four  millimetres,  or  one-sixth 
of  an  inch,  long.  It  consists  of  four  seg- 
ments, of  which  the  last  alone  has  fully- 
formed  sexual  organs.  It  is  very  com- 
mon in  dogs  of  Iceland  and  Victoria 
(Australia);  also  in  the  Icelandic  settle- 
ments in  Manitoba  (Canada),  the  dogs 
having  been  brought  from  Iceland.  The 
ova  of  the  echinococcus  are  expelled  with 
the  excrement  and  find  their  way  into 
the  alimentary  canal  of  man  by  water 
and  green  vegetables;  also  by  direct  con- 
tact with  infested  dogs,  to  the  hair  of 
which  ova  adhere  and  may  be  carried  to 
the  mouths  of  those  who  touch  the  dogs. 
The  disease  is  rare  in  Canada  and  the 
United  States,  as  well  as  in  European 
countries,  because  the  dogs  are  rarely  in- 
fested, else,  of  necessity,  hydatids  would 
be  of  frequent  occurrence  among  all 
classes,  irrespective  of  habits  as  to  clean- 
liness. 

Morbid  Anatomy. — The  ovum,  having 
entered  the  human  stomach,  loses  its 
covering  by  digestion,  setting  free  the 
larva,  which,  by  its  hooklets,  burrows 
through  the  intestinal  wall.  Some  of 
them  meet  with  and  enter  a  branch  of 
the  portal  vein  and  are  carried  to  the 
liver,  where  they  lose  their  hooklets,  and 
their  cystic  development  begins.  The 
cyst  contains  a  clear  non-albuminous 
fluid  inclosed  in  a  capsule  of  two  layers. 
There  is  an  outer,  thick,  homogeneous, 
laminated,  elastic  membrane  which  coils 
upon  itself  wherever  cut  and  if  with- 
drawn displays  a  tremulous  motion. 
This  is  the  ectocyst  of  Huxley.  Within 
and  closely  in  contact  to  this  lies  the 
endocyst:  a  delicate,  thin,  soft,  granu- 
lated membrane,  forming  the  vital  part 
of  the  bladder-worm.  Outside  the  cap- 
sule there  is  usually  a  thick  investment 
derived  from  the  tissues  of  the  infested 
organ.  After  the  cyst  has  attained  con- 
siderable size  buds  are  produced  from 


the  inner  membrane  which  gradually 
develop  into  cysts  having  the  two  walls 
identical  with  the  parent-cyst.  From 
these  daughter-cysts  similar  buds  de- 
velop and  from  a  tertiary  series  —  the 
granddaughter-cysts,  and  so  on  indef- 
initely. In  time  each  of  these  cysts 
severs  its  attachment  to  the  parent  and 
becomes  independent.  From  the  inner 
membrane  or  endocyst  of  all  these  cysts 
buds  arise  and  become  transformed  into 
scolices,  or  echinococcic  heads,  present- 
ing a  circle  of  hooklets  and  form  sucking 
disks.  Each  of  these,  transferred  to  the 
intestine  of  a  dog,  may  develop  into  a 
tape-worm.  The  exact  manner  of  the 
development  of  these  buds  is  in  dispute. 
It  is  thus  apparent  that  there  is  a  strik- 
ing contrast  between  the  development 
of  this  parasite  and  of  the  Tcenia  solium. 
The  ovum  of  the  latter  develops  into 
only  one  larva  capable  of  producing  only 
one  tape-worm,  while  the  ovum  of  the 
Tcenia  echinococcus  produces  a  larva 
capable  of  multiplying  itself  indefinitely, 
so  that  from  it  an  innumerable  number 
of  tape-worms  may  result. 

The  hydatid  cyst  is  usually  single,  the 
daughter-cysts  being  in  the  cavity  of  the 
mother-cyst,  which  may  be  of  enormous 
size,  filling  the  abdomen  and  pushing  the 
diaphragm  high  into  the  thorax.  The 
liver-tissue  is  atrophied  in  proportion  to 
the  size  of  the  cyst;  that  is,  the  pressure 
to  which  it  is  subjected.  The  parasite 
may  die.  Then  the  fluid  becomes  ab- 
sorbed, the  capsule  shrivels,  and  within 
its  remains  are  found  fat-drops,  choles- 
terin  crystals,  and  hooklets.  The  capsule 
may  become  inflamed  and  an  abscess  re- 
sult. 

In  lower  animals  the  cyst  may  be 
multiple,  the  daughter-cysts  developing 
outward  from  the  mother-cyst:  exoge- 
nous. 

A  third  form  is  multilocular.    In  this 


414       LIVER,  DISEASES  OF  THE.    HYDATID  CYST.    PROGNOSIS.  TREATMENT. 


the  daughter-cysts  are  surrounded  by 
fibrous  tissue  and  all  become  consolidated 
into  a  multilocular  mass  resembling  a 
colloid  cancer,  for  which  it  was  formerly 
mistaken. 

Prognosis. — Hydatid  cyst  of  the  liver 
is  a  serious  disease,  proving  fatal  in 
about  25  per  cent,  of  the  cases.  The 
course  of  the  disease  is  chronic,  some- 
times lasting  as  long  as  thirty  years,  Ke- 
covery  may  follow  death  of  the  echino- 
coccus,  which  occurs  occasionally,  pos- 
sibly from  escape  of  bile  or  blood  into 
the  cyst.  As  a  rule,  the  cyst  ruptures 
on  account  of  its  continued  increase  in 
size.  The  rupture  may  take  place  into 
the  peritoneal  cavity  and  is  usually  fatal 
from  shock;  the  fluid,  being  sterile,  does 
not  cause  peritonitis.  If  inflammatory 
adhesions  to  the  colon,  stomach,  small 
intestine,  or  right  kidney  have  preceded 
the  rupture,  the  cyst  may  rupture  into 
one  of  these  organs,  with  discharge  of 
the  fluid  by  vomiting,  diarrhoea,  or  with 
the  urine.  If  the  cyst  is  situated  in  the 
dome  of  the  liver  it  may  rupture  into  the 
pleura  or  pericardium.  The  latter  is 
fatal,  but  recovery  may  follow  discharge 
through  a  bronchus.  Rupture  may  occur 
into  the  hepatic  vein,  or  the  vena  cava 
and  cause  sudden  death.  The  cyst  may 
open  into  the  bile-passages  and  recov- 
ery follow,  although  grave  symptoms 
usually  result  from  obstruction  and  sec- 
ondary infection. 

The  most  favorable  result  is  by  ad- 
hesion to  the  abdominal  wall  and  per- 
foration externally,  usually  near  the 
umbilicus.  The  cyst  frequently  sup- 
purates, pyogenic  organisms  gaining  ac- 
cess to  the  cavity  by  the  blood  or  bile, 
or  from  a  neighboring  inflammatory 
focus.  As  in  abscess,  the  pus  here  also 
is  said  to  be  usually  sterile. 

Treatment.  —  Operation  alone  offers 
hope  of  relief,  and  brilliant  results  have 


followed  such  intervention.  The  simplest 
operation  consists  in  aspiration,  and  is 
frequently  successful.  If  not  successful, 
injection  of  antiseptic  fluid  should  be 
resorted  to.  Various  antiseptics  have 
been  recommended,  the  last  of  which  is 
probably  silver-nitrate  solution  (1  to 
500).  It  is  said  to  act  by  precipitating 
the  chlorides  and  leading  to  the  death 
of  the  parasite. 

Five  cases  of  hydatid  cysts  treated  by 
incision  with  but  1  death.  In  10  other 
cases  after  completely  emptying  the  cyst, 
1  teaspoonful  of  a  solution  of  sublimate 
1  to  1000  was  injected,  8  cures  being  ob- 
tained. Bouilly  (Med.  Press  and  Circu- 
lar, May  4,  '92). 

Sudden  death  of  a  child  of  5  years  fol- 
lowing the  injection  of  glycerin  solution 
of  bichloride  of  mercury  into  an  eehino- 
coccic  cyst.  The  autopsy  revealed  a  per- 
foration of  the  cyst-wall  through  which 
the  liquid  had  passed  into  the  peritoneal 
cavity.  Felizet  (Le  Bull.  Med.,  Feb.  26, 
'93). 

Aspiration  performed  only  in  cases  of 
simple  cysts  of  the  liver  without  daugh- 
ter-progeny, and  in  those  that  have  not 
suppurated.  Reference  made  to  Davie* 
Thomas's  statistics, — 411  tapping-opera- 
tions on  liver-cysts:  73  died,  5  not  re- 
lieved. 92  failed  to  cure,  68  relieved,  163 
reputed  cured,  and  10  cases  result  un- 
known. Alexander  H.  Ferguson  (An- 
nual. '94). 

Statistics  of  abdominal  section  for  hy- 
datid of  the  liver  show  extremely  favor- 
able results, — 68  cases,  with  7  deaths. — 
within  a  fraction  of  90  per  cent,  of  re- 
coveries. The  method  of  operation  by 
two  stages,  producing  peritoneal  adhesion 
by  incision  and  packing  with  carbolized 
gauze,  showed  a  mortality  of  a  fraction 
over  19  per  cent.:  the  operation  by  caus- 
tics gave  a  mortality  of  33.68  per  cent., 
while  that  by  canule  a  demeure  was  26.66 
per  cent.  Thoracic  incisions  for  hydatids 
of  the  liver  occupying  the  convexity  of 
the  organ  show  a  high  rate  of  mortality. 
Where  an  hydatid  cyst  of  the  liver  has 
ruptured  into  the  pleura,  free  incision 
into  the  pleural  cavity  appears  to  be  the 


LIVER,  DISEASES  OF  THE.    AMYLOID  LIVER.  SYMPTOMS. 


415 


only  treatment  which  holds  out  a  fair 
promise  of  success.  Thomas  (Brit.  Med. 
Jour.,  Sept.  28,  '89). 

Literature  of  '96-'97-'98. 

Method  of  Baccelli,  which  consists  of 
injection  into  the  cyst  of  20  cubic  centi- 
metres of  distilled  water  containing  0.02 
gramme  of  corrosive  sublimate  after  the 
withdrawal  of  30  cubic  centimetres  of  the 
liquid,  should  be  practiced  in  the  treat- 
ment of  echinococcic  cysts  before  a  for- 
mal operation  is  undertaken.  Stefanile 
(Riforma  Med.,  No.  76,  '96). 

The  true  surgical  treatment  of  hy- 
datid cysts  of  the  liver  consists  in  direct 
incision  made  by  the  anterior  abdominal 
route,  by  the  transpleural  route,  or  by 
the  lumbar  incision.  Median  or  lateral 
laparotomy  should  be  reserved  for  antero- 
inferior or  antero-superior  cysts.  The 
transpleural  route  with  resection  of  the 
ribs  is  the  best  way  of  reaching  sub- 
diaphragmatic cysts  which  are  deeply 
placed.  Lumbar  incision  allows  the  sur- 
geon to  reach  cysts  in  the  posterior  and 
lower  part  of  the  liver.  Bolognesi  (Bull. 
Gen.  de  Ther.,  Mar.  30,  '96) . 

In  hydatids  of  the  liver:  an  incision 
over  the  most  prominent  part  of  the  mass 
should  be  made,  if  a  mass  can  be  de- 
tected; but,  if  no  tumor  is  obvious,  the 
guide  to  incision  is  the  area  of  hardening 
and  of  dullness  on  percussion.  They 
should  be  produced  by  suturing  the  peri- 
toneum around  the  mass.  The  aspirator 
is  used  to  prove  diagnosis,  always  bear- 
ing in  mind  the  possibility  that  typical 
fluid  will  not  appear,  as  it  may  be  too 
thick  to  enter  the  needle.  When  it  has 
been  found  necessary  to  produce  adhe- 
sions artificially  the  surgeon  waits  for 
several  days  before  opening  the  cyst. 
The  opening  made  in  the  cyst-wall  should 
be  of  sufficient  size  to  admit  a  large-sized 
drainage-tube.  The  dressing  must  be 
conducted  with  the  strictest  antiseptic 
care.  For  the  first  week  after  operation 
the  cyst-cavity  should  be  washed  out 
with  sterile  water,  after  this  with  car- 
bolic solution,  iodine  solution,  or  any  of 
the  antiseptic  solutions.  J.  Frank 
(Amor.  Jour.  Med.  Sci.,  Oct.,  '96). 

In  resection  of  the  liver  for  echinococ- 
cus  stress  laid  on  the  value  of  a  prelimi- 


nary ligature  passed  through  the  whole 
substance  of  the  liver,  so  as  to  keep  the 
organ  well  in  the  abdominal  wound.  Pal- 
leroni  (Gazz.  degli  Osped.,  Aug.  7,  '98). 

Free  incision  and  drainage  are  being 
resorted  to  more  frequently  of  late,  and 
with  results  that  justify  such  radical 
means. 

Electrolysis  and  potassium  iodide  have 
been  successful  in  a  few  cases. 

Amyloid  Liver. 

Symptoms. — There  are  no  characteris- 
tic symptoms  of  amyloid  liver.  The  pa- 
tient presents  the  symptoms  of  the  pri- 
mary disease  to  which  the  amyloid 
change  is  due.  He  is  pale,  cachectic,  and 
later  may  be  dropsical.  There  is  no 
jaundice  or  bile-pigment  in  the  urine. 
Bile  is  secreted  and  flows  into  the  in- 
testines, coloring  the  contents.  There  is 
disturbance  of  digestion  and  often  diar- 
rhoea, on  account  of  the  amyloid  deposit 
in  the  intestine.  The  urine  is  usually 
copious,  pale,  of  low  specific  gravity,  and 
contains  much  albumin  on  account  of 
the  amyloid  disease  of  the  kidneys. 

On  physical  examination  the  liver  is 
found  large,  firm,  smooth,  and  not  ten- 
der. Its  lower  edge  is  usually  rounded, 
but  sometimes  sharp,  and  not  rarely  as 
low  as  the  iliac  crest.  There  are  no  signs 
of  portal  obstruction.  The  spleen  may 
be  large,  on  account,  chiefly,  of  the  amy- 
loid change  in  it. 

Course  and  Duration.  —  The  general 
condition  grows  gradually  worse,  the  sur- 
face becomes  an  earthy  pallor,  which, 
some  believe,  is  characteristic,  and  the 
patient  dies  from  exhaustion,  if  not  cut 
off  by  an  intercurrent  affection  or  a  "ter- 
minal infection."' 

The  duration  of  the  disease  is  usually 
several  years,  although  occasional  cases 
run  their  course  in  a  few  months. 

Diagnosis. — This  is  usually  easy  from 


416 


LIVER,  DISEASES  OF  THE.    FATTY  INFILTRATIOX. 


the  associated  conditions.  The  occur- 
rence of  progressive  enlargement  of  the 
liver  in  a  case  of  long-standing  suppura- 
tion, especially  of  a  tuberculous  or  syphi- 
litic character,  renders  the  diagnosis  al- 
most certain.  The  co-existence  of  de- 
generation of  the  kidneys,  spleen,  and 
intestines  adds  to  the  certainty  of  the 
•diagnosis. 

Etiology. — In  amyloid  liver  a  deposit 
of  waxy  material  takes  place  in  the 
blood-vessels  and  interstitial  tissue  of  the 
liver.  It  occurs  as  part  of  a  general  de- 
generation in  certain  constitutional  con- 
ditions of  which  prolonged  tuberculous 
suppurations  of  the  bones,  lungs,  and 
urinary  tract  are  the  most  frequent. 
Next  to  these,  syphilitic  suppurations  are 
the  most  common  causes;  but  the  amy- 
loid change  may  occur  in  syphilis  with- 
out suppuration.  It  is  also  occasionally 
found  in  rickets,  Bright's  disease,  leu- 
kaemia, malignant  disease,  and  in  pro- 
tracted convulsions  from  infectious 
fevers. 

Morbid  Anatomy. — In  advanced  stages 
the  liver  is  greatly  and  uniformly  en- 
larged. Its  size  may  be  doubled  and  its 
weight  more  than  trebled.  The  surface 
is  smooth,  firm,  and  of  a  slightly  glisten- 
ing yellowish-gray  color.  On  section  the 
surface  has  an  anasmic,  waxy  appearance, 
is  semitranslucent  in  thin  sections,  and 
the  infiltrated  areas  stain  a  rich  mahog- 
any-brown on  the  application  of  a  dilute 
solution  of  iodine,  while  the  normal  parts 
become  a  light  yellow. 

The  morbid  change  usually  affects  the 
capillaries  in  the  middle  zone  of  the 
hepatic  lobules  first,  and  later  the  inter- 
lobular vessels  and  connective  tissue.  In 
the  capillaries  "the  amyloid  substance 
lies  between  the  endothelium  and  the 
liver-cells,  and  the  latter  atrophy  appar- 
ently because  of  the  pressure  which  the 
amyloid  substance  exerts.    Some  of  the 


cells  show  fatty  and  albuminous  degener- 
ation" (Thoma). 

Similar  changes  are  usually  found  in 
the  spleen,  kidneys,  and  mucous  mem- 
branes of  the  intestines. 

Prognosis.  —  The  prognosis  is  bad. 
Many,  however,  claim  that  a  cure  is  pos- 
sible in  the  initial  stage  if  the  cause  is 
removed. 

Treatment.  —  There  is  no  effective 
remedy  for  the  disease  known;  therefore 
the  treatment  should  be  prophylactic. 

Tuberculous  disease  of  bones  should  be 
treated  surgically  and  cured  as  soon  as 
possible,  as  should  also  chronic  suppura- 
tions of  all  kinds.  Syphilis  should  be 
vigorously  treated.  The  patient  should 
be  nourished  and  the  strength  main- 
tained as  well  as  possible. 

Fatty  Liver. 

Fatty  liver  occurs  under  two  forms: 
fatty  infiltration  and  fatty  degeneration. 
The  former  represents  a  normal  condi- 
tion, since  liver-cells  always  contain  some 
minute  globules  of  fat.  In  this  form  the 
particles  of  fat  penetrate  the  liver-cells, 
where  they  coalesce  into  growing  drop- 
lets and  push  aside  the  cell-protoplasm 
and  often  destroy  it  by  interfering  with 
its  nutrition. 

In  fatty  degeneration  there  is  a  conver- 
sion of  the  protoplasm  itself  of  the  cell 
into  fat  probably  by  the  action  of  some 
toxic  agents,  such  as  phosphorus. 

Fatty  Infiltration. 

Symptoms. — There  are  no  distinctive 
symptoms.  The  liver  may,  if  large,  be 
felt  to  be  smooth,  soft,  not  tender,  and 
with  rounded  edges.  There  is  no  jaun- 
dice. Addison  long  ago  drew  attention 
to  a  scmitransparent,  pale,  smooth,  soft 
skin,  feeling  like  softest  satin,  occurring 
in  fatty  liver.  lie  considered  it  almost 
pathognomonic.  And  Hebra  noticed  a 
similar  condition  of  skin  in  habitual 


LIVER  AND  GALL-BLADDER.  ANGIOCHOLITIS. 


417 


spirit-drinkers,  and  in  them  fatty  liver  is 
common. 

Diagnosis. — The  fatty  liver  can  usually 
be  recognized  by  its  soft,  smooth  charac- 
ter and  its  occurring  in  the  obese  or  the 
emaciated.    The  large  amyloid  liver  is  | 
distinguished  by  being  firm,  larger,  and  j 
by  the  history  of  the  cause  and  the  evi-  J 
dence  of  renal  disease. 

Etiology.  —  The     conditions  under 
which  fatty  infiltration  occurs  may  be 
divided  into  two  main  classes,  strikingly 
in  contrast  with  one  and  other.    In  one 
class  the  fatty  liver  results  from  dietetic 
errors,  from  eating  an  oversupply  of  rich 
food,  and  as  a  part  of  general  obesity, 
chiefly  in  persons  of  sedentary  habits. 
The  blood  is  overcharged  with  fat,  of 
which  much  is  stored  in  the  hepatic  cells. 
Phloridzin  produces  fatty  liver  under 
certain  conditions.   Dogs  were  kept  with- 
out food  for  five  days;  then  on  the  sixth 
and  seventh  days  2  1/2  drachms  of  phlorid- 
zin were  given.    The  animals  were  killed 
on  the  eighth  day,  forty-eight  hours  after 
the  first  dose  of  phloridzin.  Well-marked 
fatty  liver  was  found.    The  liver  of  dogs 
kept  without  food  for  seven  days  con- 
tained 10  per  cent,  of  fat,  while,  if  phlorid- 
zin had  been  given  the  amount  of  fat 
was  25.3  to  74.5  per  cent.   The  fatty  con- 
dition of  the  liver  produced  by  phloridzin 
alone  did  not  occur  if  the  animal  was  fed 
on  nitrogenous  and  saccharin  food,  but 
fatty  food  increased  the  fatty  infiltration 
of  the  liver.    (Zeit.  f.  klin.  Med.,  B.  28, 
H.  3,  4.) 

The  other  class  consists  of  cachectic 
cases,  of  which  pulmonary  phthisis  fur- 
nishes the  greater  number.  In  these,  on 
account  of  the  low  powers  of  oxidation, 
even  the  small  amount  of  food  that  is 
taken  is  not  properly  oxidized  and  much 
of  it  is  converted  into  fat  and  deposited 
in  the  liver-cells. 

Morbid  Anatomy. — The  liver  is  large, 
smooth,  and  soft.  It  may  weigh  ten  or 
twelve  pounds.  The  edge  is  thick  and 
rounded.    The  deposit  of  fat  begins  in 

4— 


the  cells  at  the  periphery  of  the  lobule, 
and  in  time  distends  them.  It  can  be 
extracted  from  the  cell  with  ether,  leav- 
ing the  cell  shrunk. 

The  specific  gravity  of  the  liver  is  re- 
duced, so  that  the  whole  organ  floats 
when  placed  in  water. 

Prognosis. — This  will  depend  on  the 
cause.  If  the  condition  that  leads  to  the 
deposit  of  fat  in  the  liver  is  relieved  the 
further  deposit  of  fat  will  cease  and  the 
hepatic  cells  will  gradually  be  restored 
to  their  normal  condition. 

Treatment. — Treatment  should,  there- 
fore, be  directed  to  the  cause  of  the  con- 
dition. In  the  obese  there  should  be  a 
careful  regulation  of  diet,  with  a  view  to 
lessening  the  formation  of  fat  while  sus- 
taining the  strength.  Habits  of  early 
rising  and  active  exercise  should  be  en- 
couraged, care  being  taken  not  to  induce 
overfatigue,  especially  if  the  heart  shows 
signs  of  weakness,  as  it  often  does  from 
fatty  infiltration  or  degeneration.  Water 
should  be  freely  taken  on  an  empty  stom- 
ach, and  occasional  purging  resorted  to. 
Little,  if  any,  alcoholic  stimulants,  espe- 
cially beer,  should  be  allowed.  If  suffi- 
cient active  exercise  cannot  be  taken, 
massage  and  resistance  movements  will, 
to  a  great  extent,  supply  its  place. 

In  the  anaemic  form  of  fatty  liver,  such 
as  occurs  in  pulmonary  phthisis,  the 
treatment  should  aim  at  improving  the 
general  condition  without  regard  to  the 
liver. 

.  Fatty  Degeneration!  —  This  results 
from  poisoning  of  some  form,  as  in  acute 
yellow  atrophy,  in  which  the  liver- 
changes  are  typical  of  fatty  degeneration. 

Inflammation  of  the  Bile-passages  and 
Gall-bladder  (Angiocholitis  or  Cholan- 
gitis and  Cholecystitis). 

Definition. — This  consists  in  an  in- 
flammation of  the  biliary  tract.  It  may 
affect  the  common  bile-duct  and  all  its 
27 


418 


LIVER  AND  GALL-BLADDER.  ANGIOCHOLITIS. 


branches  or  any  part  of  them,  the  cystic 
duct,  or  the  gall-bladder. 

Symptoms.  —  Since  catarrhal  cholan- 
gitis nearly  always  follows  gastro-enteric 
catarrh,  the  usual  acute  dyspeptic  symp- 
toms precede  those  due  to  the  disease  of 
the  bile-ducts;  such  as  anorexia,  belch- 
ing of  gas,  epigastric  distension,  nausea, 
vomiting,  and  constipation.  These  symp- 
toms may,  however,  be  very  mild,  or 
most  of  them  may  be  absent,  and  jaun- 
dice be  the  first  symptom  noticed.  The 
jaundice  deepens  rapidly,  but  is  always 
of  a  bright-yellow  tint,  never  the  green 
or  bronzed  hue  of  that  due  to  malignant 
disease.  The  stools  are  clay-colored 
and  the  urine  contains  bile-pigment. 
The  temperature  may  be  slightly  ele- 
vated. The  pulse  is  usually  normal,  but 
may  be  slow,  being  only  40  or  50  to  the 
minute.  A  dull,  heavy,  sleepy  condition 
may  be  present.  The  liver  is  sometimes 
enlarged  and  palpable  below  the  costal 
margin. 

If  the  catarrhal  inflammation  is  con- 
fined to  the  gall-bladder  the  cystic  duct 
usually  becomes  obstructed  by  pressure 
of  the  bladder-contents  on  the  outlet. 
No  jaundice  occurs,  or  any  of  the  fore- 
going symptoms,  except  a  sense  of  press- 
ure and  sensitiveness  at  the  seat  of  the 
gall-bladder.  When  distended,  it  may, 
if  the  abdominal  wall  is  lax  and  not  too 
thick,  be  felt  as  a  pear-shaped  mass  ad- 
herent to  the  liver  and  moving  with  it. 

In  suppurative  cholangitis  the  symp- 
toms are  usually  severe,  but  may  be 
latent,  especially  if  the  disease  occurs  in 
the  course  of  an  acute  infectious  disease. 
There  is,  in  most  cases,  a  previous  his- 
tory of  gall-stones.  The  patient  usually 
suffers  from  irregularly  recurring  chills, 
with  fever  and  sweating,  the  temperature 
rising  to  104°  F.  or  more.  There  is 
swelling  and  tenderness  of  the  liver. 
Jaundice  is  always  present,  but  more  | 


variable  than  in  the  catarrhal  variety; 
it  may  be  intense.  Leucocytosis  occurs 
and  is  suggestive  of  the  condition.  Later 
the  case  presents  the  appearance  of  a 
well-marked  general  pyaemia  with  ema- 
ciation and  weakness. 

In  chronic  catarrhal  angiocholitis  the 
symptoms  may  be  very  characteristic. 
The  jaundice  may  vary  if  the  degree  of 
obstruction  alters,  as  it  often  does  when 
a  gall-stone  is  situated  in  the  diverticu- 
lum of  Vater,  where  it  may  act  as  a 
"ball-valve,"  producing  complete  ob- 
struction as  it  moves  into  the  outlet  of 
the  duct,  and,  again,  allowing  bile  to 
pass  as  it  moves  back  into  the  diverticu- 
lum. In  chronic  angiocholitis  there  are 
often  recurrent  attacks  of  fever  with 
chills  and  sweating,  the  so-called  inter- 
mittent hepatic  fever.  Such  cases  may 
have  a  history  extending  through  some 
years.  It  is  probably  to  this  class  belong 
the  cases  regarded  as  suppurative  cho- 
langitis with  a  prolonged  history  and 
ultimately  terminating  in  recovery. 

Diagnosis. — In  acute  catarrhal  cho- 
langitis the  diagnosis  is  usually  easily 
made  from  the  digestive  disturbance  and 
gradual  onset  of  the  jaundice.  Gall- 
stones are  excluded  by  the  absence  of 
colic  and  the  fact  that  the  jaundice  is 
not  of  sudden  development.  In  catar- 
rhal cholecystitis  there  is  enlargement 
of  the  gall-bladder,  which  may  be  palpa- 
ble as  a  pyriform  tumor  adherent  to  the 
liver  and  rising  and  falling  with  respira- 
tion. Xot  infrequently  a  tongue-like 
lobe  of  the  liver  is  mistaken  for  a  dis- 
tended gall-bladder.  So  may  also  a 
movable  kidney;  it  is  usually  more  easily 
displaced,  and  is  not  attached  to  the 
liver.  Instead  of  being  smooth,  rounded, 
and  clastic,  the  distended  gall-bladder 
may,  from  inflammatory  thickening,  ap- 
pear more  like  a  solid  tumor  and  be  mis- 
taken for  cancer  in  this  situation,  but 


LIVER  AND  GALL-BLADDER.  ANGIOCHOLITIS. 


419 


cancer  is  usually  associated  with  jaun- 
dice and  cachexia.  Echinococcic  cysts 
have  also  to  be  excluded;  aspiration  may 
be  necessary  to  do  so.  The  history  and 
shape  of  the  tumor  may  be  sufficient  to 
differentiate  between  the  two  conditions. 

The  diagnosis  of  suppurative  cholan- 
gitis is  to  be  made  by  a  history  of  gall- 
stones, the  occurrence  of  a  septic  condi- 
tion with  enlargement  and  tenderness  of 
the  liver,  and  the  existence  of  leucocyto- 
sis.  There  is  progressive  loss  of  flesh  and 
strength.  The  duration  rarely  exceeds 
a  few  weeks,  the  cases  lasting  months  and 
ultimately  recovering  being  most  prob- 
ably cases  of  chronic  catarrhal  cholan- 
gitis due  to  obstruction,  and  causing  in- 
termittent hepatic  fever. 

Etiology. — Inflammation  of  the  bile- 
passages  usually  results  from  extension 
of  an  inflammatory  process  from  the 
duodenum,  and  is,  in  the  majority  of 
cases,  associated  with  gall-stones.  The 
duodenal  catarrh  that  precedes  the  cho- 
langitis usually  follows  acute  indigestion. 
The  young  are  most  susceptible  to  it, 
but  it  may  occur  at  any  age.  It  occurs 
also  as  the  result  of  exposure  to  cold, 
chills,  malaria,  typhoid  fever,  pneumo- 
nia, and  in  the  course  of  Bright's  disease, 
chronic  heart  disease,  emphysema,  etc. 
It  may  occur  in  the  course  of  any  or- 
ganic disease  of  the  liver,  as  inflam- 
mation, cancer,  and  hydatids.  Chronic 
catarrhal  cholangitis  may  possibly  be  a 
sequel  to  the  acute.  It  is  always  due  to 
obstruction  of  the  common  bile-duct 
from  gall-stones,  stricture,  pressure  from 
without,  etc.  The  obstruction  may  be 
complete,  in  which  case  the  ducts  are 
greatly  dilated  and  filled  with  clear, 
watery  fluid  similar  to  that  of  dropsy  of 
the  gall-bladder.  If  the  obstruction  is 
incomplete,  there  is  less  dilatation  of  the 
ducts,  and,  as  some  bile  filters  through, 
their  contents  are  bile-stained  and  tur- 


bid. The  gall-bladder  is  not  much  di- 
lated in  these  cases,  obstruction  of  the 
cystic  duct  being  necessary  to  cause  great 
dilatation  of  it.  Gall-stones  are  usually 
found  in  it. 

Suppurative  cholangitis  is  usually  as- 
sociated with  gall-stones,  less  frequently 
with  echinococci  and  round  worms.  The 
mucosa,  injured  by  such  foreign  bodies, 
becomes  more  susceptible  to  invasion  by 
pyogenic  organisms,  and  these  are  pres- 
ent normally  in  the  intestines  and  in  the 
lowest  part  of  the  common  bile-duct. 

Morbid  Anatomy. — In  acute  catarrhal 
cholangitis  the  lower  part  of  the  com- 
mon bile-duct  is  usually  chiefly,  and  may 
be  the  only  part,  affected.  The  inflam- 
mation may  extend  to  its  larger  branches. 
Post-mortem  evidences  are  slight,  as  red- 
ness and  swelling  disappear  after  death. 
A  ping  of  inspissated  mucus  may  fill  the 
diverticulum  of  Vater  and  completely 
obstruct  the  flow  of  bile.  The  gall- 
bladder, when  affected,  contains  a  more 
or  less  viscid  mucous  secretion;  if  there 
is  obstruction  of  the  cystic  duct,  the 
bladder  becomes  distended  with  fluid,  of 
which  it  may  contain  one  or  more  pints, 
usually  thin  and  without  bile.  The  walls 
of  the  gall-bladder  are  thin  and  shining; 
but,  if  the  obstruction  persist,  they  may 
become  much  thickened. 

In  suppurative  angiocholitis  the  com- 
mon duct  becomes  greatly  dilated  and  its 
walls  much  thickened.  Similar  changes 
occur  in  the  gall-bladder.  Both  are  dis- 
tended with  pus.  Ulceration  may  occur 
and  perforation  into  the  stomach,  colon, 
or  duodenum,  or  even  into  the  urinary 
or  respiratory  tract.  The  intrahepatic 
bile-ducts  may  be  distended  with  pus, — 
which  is  usually  bile-stained.  The  sup- 
purative process  may  extend  to  the 
hepatic  substance,  resulting  in  abscess- 
formation,  or  to  the  portal  vein,  and 
pylephlebitis  result. 


420 


LIVER  AND  GALL-BLADDER.    TUMORS  OF  BILIARY  TRACT. 


The  bacteria  present  in  these  inflam-  j 
matory  processes  are  very  various.  The 
bacillus  coli  communis  probably  plays  the 
most  important  part,  but  staphylococci 
and  streptococci  are  also  common,  as 
they  are  all  present  in  the  duodenum 
in  health.  The  pneumococcus  and  the 
typhoid  bacillus  may  be  the  active 
agents. 

Treatment. — This  consists  in  measures 
to  relieve  the  gastro-duodenal  catarrh. 
Plenty  of  liquids  should  be  taken,  espe- 
cially the  alkaline  mineral  waters.  The. 
bowels  should  be  moved  freely,  but  not 
immoderately,  by  the  use  of  calomel  fol- 
lowed by  salines,  such  as  Carlsbad  salts, 
phosphate  of  soda,  etc.  Bicarbonate  of 
soda,  with  bismuth,  may  prove  useful  for 
the  gastric  disturbance.  Such  antiseptics 
as  resorcin,  guaiacol-carbonate,  and  sa- 
licylate of  bismuth  are  useful.  A  large 
cold,  rectal  enema  may  be  given  daily; 
it  is  said  to  stimulate  contraction  of  the 
gall-bladder  and  ducts  and  thus  promote 
expulsion  of  the  mucus  that  is  obstruct- 
ing the  escape  of  bile.  The  water  is  to  I 
be  retained  so  as  to  furnish  more  liquid 
for  excretion,  but  it  cannot  effect  that 
object  better  than  water  taken  by  the 
stomach. 

Light  liquid  diet  only  should  be  given, 
as  it  is  easy  of  digestion  and  less  apt  to 
ferment. 

Tumors  of  the  Biliary  Tract. 
Cancer. 

Etiology. — Cancer  may  occur  as  a 
primary  disease  of  the  gall-bladder  and 
of  the  bile-ducts  or  may  be  secondary  to 
cancer  of  the  liver,  stomach,  pancreas,  or 
peritoneum. 

Primary  cancer  of  the  gall-bladder 
affects  females  much  oftener  than  males 
— in  the  ratio  of  3  or  4  to  1.  The  bile- 
ducts  are  affected  about  equally  in  the 
two  sexes.  The  disease  occurs  usually  j 
from  forty  to  seventy,  but  occasional  ' 


cases  are  met  with  in  early  life  and  at 
advanced  age. 

Gall-stones  are  present  in  practically 
all  cases  of  cancer  of  the  gall-bladder. 
The  relationship  between  the  two  condi- 
tions is  in  dispute.  Some  regard  the 
cancer  as  developing  in  the  glands  of  the 
mucosa  on  account  of  the  irritation  by 
the  calculi;  while  others  look  upon 
them  as  formed  subsequently  to  the  com- 
mencement of  the  cancer.  The  greater 
frequency  of  occurrence  of  gall-stones 
in  females  gives  support  to  the  view  that 
their  irritation  frequently  excites  the  de- 
velopment of  cancer. 

Attention  called  to  the  frequency  with 
which  cancer  and  biliary  lithiasis  are 
associated.  Of  44  cases  of  mammary  can- 
cer in  females,  gall-stones  were  found  in 
1G  per  cent.:  a  ratio  twice  as  high  as 
that  stated  to  hold  for  women  dead  of 
causes  other  than  cancer.  Williams 
(Brit.  Med.  Jour.,  Aug.  26,  '93). 

The  disease  usually  begins  at  the 
fundus  of  the  gall-bladder,  and  at  either 
extremity  of  the  common  bile-duct. 

Cancer  of  the  Bile-ducts. 

Symptoms. — It  rarely  forms  a  tumor 
that  can  be  felt  through  the  abdominal 
wall.  The  jaundice  usually  occurs  early, 
and  is  intense  and  persistent.  The  stools 
are  persistently  clay  colored.  A  fatal 
termination  usually  follows  in  three  or 
four  months,  from  cholsemia.  It  may 
be  the  cause  of  cholangitis  with  inter- 
mittent hepatic  fever  or  there  may  be 
suppurative  cholangitis. 

Diagnosis. — It  is  practically  impos- 
sible to  make  a  positive  diagnosis  with- 
out an  exploratory  operation.  The  per- 
sistent intense  jaundice  is  suggestive,  and 
may,  in  some  cases,  render  the  diagnosis 
extremely  probable,  especially  in  the  ab- 
sence  of  biliary  colic. 

^Iokbid  Anatomy. — The  cancer  usu- 
ally develops  in  the  circumference  of  the 
duct  as  an  infiltration  of  the  submucous 


LIVER  AND  GALL-BLADDER.    CANCER  OF  THE  GALL-BLADDER. 


421 


tissue.  The  surface  of  the  deposit  may 
be  smooth  or  ulcerated.  They  occur 
most  frequently  in  the  diverticulum  of 
Vater  and  may  extend  to  the  duodenal 
papilla. 

The  epithelium  of  the  bile-ducts  may 
be  the  seat  of  the  primary  focus  of  car- 
cinoma of  the  liver.  Dallemange  (Jour, 
de  Med.,  de  Chir.,  et  de  Pharm.,  lii,  No. 
25,  '"94). 

Cancer  of  the  Gall-bladder. 

Symptoms  and  Signs. — Xot  rarely 
the  attention  is  first  arrested  by  the  acci- 
dental discovery  of  a  smooth,  firm,  egg- 
shaped  swelling  below  the  costal  margin. 
It  is  fixed  to  the  liver  and  moves  with  it 
in  respiration.  There  is  usually  a  sense 
of  discomfort  and  later  often  of  irregu- 
lar pain  in  the  neighborhood  of  the  mass. 
The  pain  is  rarely  persistent  or  severe, 
and  may  disappear  altogether.  It  is  usu- 
ally worse  at  night  and  may  extend 
around  to  the  back.  Later,  as  the  tumor 
enlarges,  it  becomes  less  defined,  and 
nodules  often  appear  on  its  surface.  If 
dissemination  has  occurred,  nodules  may 
be  felt  on  the  liver  and  in  the  perito- 
neum. Ascites  may  result  from  the  peri- 
toneal affection  or  from  pressure  by  dis- 
eased lymph-glands  on  the  portal  vein 
in  the  hilum  of  the  liver.  Jaundice  oc- 
curs in  probably  not  more  than  half  of 
the  cases;  when  it  occurs  it  is  a  late 
symptom  and  depends  on  pressure  on  the 
bile-ducts  in  the  hilum. 

There  is  usually  early  general  failure 
of  health.  In  the  later  stages  there  is 
marked  cachexia,  and  loss  of  flesh  and 
strength,  with,  not  infrequently,  mental 
weakness  and  a  prolonged  period  of  sub- 
delirium.  Adhesions  to  the  intestines 
may  give  rise  to  symptoms  of  partial  or 
complete  obstruction. 

The  course  is  usually  rapid,  death  oc- 
curring in  a  few  months  after  the  ap- 
pearance of  the  tumor. 


i     Diagnosis. — The  presence  of  a  tumor 
and  the  progressive  character  of  the 
local  and  general  symptoms  of  the  dis- 
|  ease  usually  suffice  for  a  diagnosis.  In 
the  absence  of  a  tumor  the  diagnosis  is 
|  difficult  and  may  be  impossible,  as  it  may 
be  also  to  distinguish  a  tumor  formed 
by  matted  intestine  from  local  peritonitis 
from  a  tumor  of  the  gall-bladder.  Even 
i  incision  and  exploration  not  rarely  fail 
to  clear  up  the  difficulty. 

Tumors  of  the  pylorus,  of  the  trans- 
verse colon,  of  the  kidney,  and  of  the 
suprarenal  gland  may  simulate  tumor  of 
the  gall-bladder. 

Tumors  of  the  biliary  passages,  or  lo- 
cated in  the  neighborhood  of  the  liver, 
may  give  rise  to  ballottement,  simulating 
that  obtainable  in  certain  kidney  affec- 
tions. Dentu  (Le  Bull.  Med.,  Feb.  12, 
'93). 

Morbid  Anatomy. — The  cancer  may 
begin  at  the  fundus  or  near  the  cystic 
duct,  but  often  the  walls  of  the  gall- 
bladder are  found  uniformly  thickened. 
The  diseased  gall-bladder  may  form  a 

j  large,  smooth  or  nodular  mass  adherent 
to  the  liver  and  to  the  intestines,  and  in 
the  centre  of  the  mass  a  considerable 
cavity  filled  with  opaque  gray  fluid  con- 
taining much  flocculent  material  and 
several  gall-stones.  The  cancer  is  usu- 
ally a  cylindrical  epithelioma,  but  it 
varies  much.  It  may  extend  into  the 
liver  directly  or  by  way  of  the  portal 
fissure,  where  it  may  affect  the  portal 
vein  and  give  rise  to  multiple  deposits 
in  the  liver.  The  lymph-glands  in  the 
hilum  of  the  liver  are  usually  affected. 

Treatment. — Symptomatic  treatment 
is  usually  all  that  can  be  carried  out.  If 
the  disease  is  recognized  early  before  it 
has  affected  neighboring  structures  cho- 

I  lecystectomy  may  be  practicable.  Mayo 
Kobson  reports  such  a  case  in  which  he 
removed  a  large  portion  of  the  right  lobe 
of  the  liver  with  (he  gall-bladder.  The 


422        LIVER  AND  GALL-BLADDER.    EMPYEMA  OF  THE  GALL-BLADDER. 


patient  made  a  good  recovery.  Other 
similar  cases  have  been  lately  reported. 
Other  tumors  cf  the  bile-ducts  are  rare. 

Fibromata  have  been  met  with.  Adeno- 
mata occur  occasionally.  I  met  with  one 
of  the  diverticulum  of  the  common  duct 
in  a  man  aged  50  years.  A  gradually- 
increasing  jaundice  was  the  first  symp- 
tom. Later  suppurative  cholangitis  oc- 
curred, with  chills,  high  fever,  and 
tender  liver.  At  the  autopsy  the  mass 
in  the  duct  was  found  to  act  like  a  ball- 
valve,  obstructing  the  discharge  of  bile. 

There  may  exist  true  adenomata  of  the 
bile-duets  in  livers  otherwise  little 
altered,  and  these  adenomata  may  un- 
dergo cystic  dilatation;  they  are  of  a 
benign  nature,  not  giving  rise  to  metas- 
tasis and,  unless  considerable  extension 
takes  place,  they  may  not  give  rise  to 
any  clinical  manifestation.  Von  Hippel 
(Virchow's  Archiv,  No.  3,  '91). 

Acute  Empyema  of  the  Gall-bladder 
(Acute  Infectious  Cholecystitis;  Acute 
Phlegmonous  Cholecystitis) . 

Symptoms. — The  onset  is  usually  sud- 
den, with  pain  in  the  right  side  of  the 
abdomen  in  its  upper  part,  but,  as  in 
appendicitis,  the  pain  may  be  general 
over  the  abdomen.  Nausea,  vomiting;  a 
rapid,  feeble  pulse;  thoracic  breathing, 
rise  of  temperature,  prostration,  disten- 
sion, and  tenderness  of  the  abdomen  are 
the  chief  symptoms.  In  the  cases  in 
which  the  disease  is  circumscribed  local 
tenderness  soon  becomes  more  marked. 
Jaundice  is  not  usually  present.  Intes- 
tinal symptoms  may  be  marked  and  not 
infrequently  lead  to  a  diagnosis  of  acute 
intestinal  obstruction. 

Diagnosis. — This  is  often  impossible, 
especially  in  the  fulminating  cases.  It 
is  most  often  confounded  with  gangre- 
nous appendicitis.  In  the  less  severe 
cases  the  signs  of  local  disease — as  pain, 
tenderness,  signs  of  exudation,  abdom- 
inal tension,  etc. — may  be  sufficient  to 


distinguish  between  the  two  diseases,  un- 
less the  appendix  is  situated  abnormally 
high. 

Perforation  of  the  stomach,  the  duo- 
denum, the  colon,  the  gall-bladder,  etc., 
usually  causes  greater  collapse  at  first 
and  less  marked  septic  symptoms  later. 

Etiology.  —  Acute  empyema  of  the 
gall-bladder  is  a  rare  disease.  Cases  have 
been  reported  from  time  to  time  during 
the  last  few  years.  In  about  75  per  cent, 
of  cases  it  is  associated  with  gall-stones. 
It  is  doubtless  due  to  infection  by  bac- 
teria which  may  gain  access  by  way  of 
the  blood  or  the  bile.  The  typhoid  bacil- 
lus, the  colon  bacillus,  the  pneumococ- 
cus,  and  the  staphylococcus  are  the  or- 
ganisms most  frequently  present.  Quite 
a  large  number  of  cases  have  followed 
typhoid  fever,  in  some  instances  months 
after  convalescence. 

A  comparison  has  been  drawn  between 
the  causation  of  this  disease  and  of  ap- 
pendicitis, the  gall-bladder  affection  be- 
ing of  less  frequent  occurrence  on  ac- 
count of  its  ampler  blood-supply. 

Morbid  Anatomy. — The  gall-bladder 
is  distended,  but  not  large,  not  contain- 
ing more  than  a  few  ounces  of  muco-pus. 
There  is  a  strong  tendency  to  gangrene, 
proportioned  to  the  virulence  of  the  in- 
fection and  the  tension  of  the  organ. 
The  course  is  rapid,  usually  within  four 
or  five  days.  Adhesions  are  early  formed 
to  the  intestines,  omentum,  etc.  Later, 
perforation  may  occur  and  abscess  result, 
or  an  abscess  may  form  without  perfora- 
tion. In  the  severe  cases  general  peri- 
toneal infection  is  liable  to  occur.  The 
contents  of  the  gall-bladder  may  be  very 
foetid. 

Treatment. — Acute  empyema  of  the 
gall-bladder  is  so  rapidly  fatal  that  only 
prompt  measures  are  successful.  As 
in  phlegmonous  appendicitis,  so  here 
prompt  surgical  treatment  is  necessary. 


LIVER  AND  GALL-BLADDER. 


LOBELIA. 


423 


The  real  difficulty  is  in  making  the  diag- 
nosis. In  the  early  stage  care  should 
be  taken  not  to  obscure  the  symptoms  by 
the  undue  use  of  opium.  The  temporary 
measures  should  consist  in  absolute  rest, 
hot  applications,  complete  abstinence 
from  food,  water  only  being  given  by 
the  mouth,  and  relief  of  symptoms  as 
far  as  possible  until  the  necessity  for 
operation  is  established  when  the  gall- 
bladder, if  there  is  empyema  or  gangrene 
of  it,  should  be  incised  and  drained  or 
removed.  In  milder  cases,  in  which  the 
disease  is  localized,  it  is  probably  wiser 
to  delay  operation  until  the  disease  has 
been  well  circumscribed  by  the  inflam- 
matory process,  when  incision  and  drain- 
age may  be  carried  out  and  gall-stones, 
if  present,  removed. 

Alexander  McPhedran, 

Toronto. 

LOBAR  PNEUMONIA.  See  Pneu- 
monia. 

LOBELIA. — Lobelia  is  the  dried  leaves 
and  tops  of  the  Lobelia  inflata,  or  Indian 
tobacco,  a  weed  indigenous  to  the  United 
States,  collected  after  a  portion  of  the 
capsules  have  become  inflated.  It  is  a 
small  herb,  with  alternate  leaves,  an  erect 
hairy  stem,  with  blue  flowers  in  the  axils 
of  the  leaves.  The  herb  has  a  slightly- 
irritating  odor,  and  a  burning,  tobacco- 
like taste.  It  contains  a  liquid  alkaloid, 
lobeline,  and  an  acid,  lobelic  acid;  gum 
resin,  fixed  oil,  lignin,  salts,  chlorophylle, 
and  a  volatile  oil. 

Preparation  and  Doses. — Lobelia,  1  to 
10  grains.  Extractum  lobelia1  fluidum,  1 
to  5  minims  (10  to  30  minims — emetic). 
Tinctura  lobelia?,  8  to  15  minims  (30  to 
GO  minims — emetic). 

Physiological  Action. — Excessive  doses 
of  lobelia  give  rise  to  nausea,  violent 
vomiting,  cold  sweats,  pallor,  marked 


prostration,  muscular  weakness,  and  oc- 
casionally purging.  If  the  drug  is  not, 
in  part,  vomited,  all  these  symptoms  in- 
crease in  intensity  and  the  patient  falls 
into  collapse,  soon  followed  by  death. 
These  phenomena  bear  out  the  prevail- 
ing view  that  paralysis  of  the  motor 
nerves  is  the  predominant  influence  of 
the  drug  when  taken  in  poisonous  doses. 
Dresser  found  that  lobelia  and  its  alka- 
loid, lobeline,  stimulated  the  anterior 
section  of  the  spinal  cord.  In  frogs  lobe- 
line causes  loss  of  co-ordination  and  dis- 
turbances of  respiration.  Ott  observed 
that  there  occurred  at  first  an  immediate 
fall  of  arterial  pressure,  then  a  rise:  a  re- 
sult apparently  ascribable  to  the  asphyxia 
induced  through  the  influence  of  the 
drug  upon  the  respiratory  centres.  Fur- 
ther experiments  showed,  however,  that 
the  rise  of  pressure  was,  in  part,  due  to 
peripheral  vasomotor  stimulation.  In 
therapeutics,  therefore,  the  cardinal 
points  to  be  borne  in  mind  are  that  the 
effects  of  lobelia  are  primarily  exerted 
upon  the  respiratory  centres,  the  effects 
upon  the  vasomotor  system  and  the  cir- 
culation being  secondary  factors. 

Lobeline  is  a  respiratory  poison,  as 
warm-blooded  animals  succumb  to  pa- 
ralysis of  respiration.  In  dogs  it  pro- 
duces loss  of  voluntary  movements  and  a 
concomitant  exaggeration  of  the  reflexes. 
Later,  it  produces  paralysis  of  motor 
nerves,  like  curara.  As  it  paralyzes  the 
cardiac  branch  of  the  pneumogastric 
nerves,  it  may  be  included  under  the 
nicotine  group.  Lobeline  causes  an  ac- 
celeration of  the  respiratory  movements, 
which  is  more  persistent  when  the  vagi 
are  intact.  Further,  it  augments  the 
power  of  the  respiratory  muscles.  Small 
doses  suppress  the  inhibitory  influence  of 
the  pneumogastrics  on  the  heart.  While 
it  stimulates  the  respiratory  functions,  it 
does  not  depress  the  system  like  hydro- 
cyanic acid,  and  in  energy  it  even  sur- 
passes aspidospermine.  H.  Dresser  (Arch, 
f.  exper.  Path.  u.  Pharm.,  B.  26,  H.  3,  4, 
'90). 


424 


LOBELIA. 


LOCOMOTOR  ATAXIA. 


At  first  lobeline  causes  an  increased  I 
secretion  of  the  sudoriferous  glands,  these 
effects  lasting  from  five  to  six  minutes. 
This  increase  is  followed  by  a  decrease, 
which,  although  not  so  pronounced  as 
that  produced  by  atropine,  lasts  for  sev- 
eral hours.  P.  Aubert  (Lyon  Med.,  Dec, 
'93). 

Poisoning  by  Lobelia. — The  symptoms 
of  poisoning  by  lobelia  or  its  alkaloid — 
lobeline — are  much  the  same  as  those 
due  to  tobacco  poisoning.  Giddiness, 
faintness,  trembling  of  the  limbs,  clammy 
sweats,  frequent  and  prolonged  vomiting 
accompanied  by  the  most  intense  pros- 
tration, violent  abdominal  and  oesoph- 
ageal pains,  with  occasional  purging. 
The  pulse,  at  first  weak,  becomes  almost 
imperceptible.  The  breathing  becomes 
shallow  and  difficult.  The  vision  is 
affected.  Stupor  is  followed  by  coma  or 
convulsions,  more  or  less  paralysis,  col- 
lapse, and  death  by  paralysis  of  the  mus- 
cles of  respiration.  Vomiting  is  occa- 
sionally absent,  and  then  the  constitu- 
tional symptoms  are  accentuated,  and 
death  is  apt  to  follow.  One  drachm  of 
the  powdered  leaves  has  proved  fatal  in 
about  thirty-six  hours.  On  post-mortem 
examination  the  brain  was  found  con- 
gested and  the  gastric  mucous  membrane 
inflamed. 

Treatment  of  Poisoning  by  Lobelia. — 
The  treatment  of  poisoning  by  lobelia 
consists  in  washing  out  the  stomach  by 
means  of  the  stomach-siphon.  Solutions 
of  tannic  or  gallic  acid  may  be  given  fol- 
lowed by  the  hypodermic  injections  of 
stimulants:  alcohol,  ether,  ammonia,  and 
strychnine.  The  recumbent  position 
should  be  maintained,  and  warmth  ap- 
plied to  the  extremities.  Opium  given  in 
full  doses  will  relieve  the  pain,  and  later 
in  moderate  doses  will  control  the  vomit- 
ing. 

Therapeutics. — Lobelia  is  chiefly  used 
as  an  antispasmodic  for  the  relief  of 


asthma  of  the  gastric  or  bronchial  form. 
If  the  asthma  is  due  to,  or  associated 
with,  cardiac  disease,  lobelia  should  not 
be  used.  The  drug  should  be  taken  in 
doses  of  y2  to  1  drachm  of  the  tincture 
at  the  beginning  of  the  attack,  or  in  10- 
drop  doses  every  quarter  of  an  hour  until 
nausea  appears  or  relief  is  obtained.  A 
feeble  heart  contra-indicates  its  use. 
Children  are  more  tolerant  of  the  drug 
than  adults.  Other  spasmodic  affections 
have  been  treated  with  lobelia, — pertus- 
sis, chorea,  epilepsy,  convulsions,  and 
tetanus, — but  other  remedies  equally 
efficacious  and  less  dangerous  are  to  be 
preferred. 

In  bronchial  cough  with  scanty  expec- 
toration and  bronchial  spasm,  it  is  some- 
times useful  as  a  depressing  expectorant. 

Habitual  constipation  due  to  intestinal 
atony  and  deficient  secretion  is  often  re- 
lieved by  10-minim  doses  of  the  tincture, 
given  at  bed-time.  Its  value  is  enhanced 
by  combining  it  with  cascara  sagrada. 
Lobelia  in  infusion  (1  ounce  to  the  pint) 
is  useful  as  a  lotion  in  the  treatment  of 
the  dermatitis  due  to  poison-ivy  {Rhus 
toxicodendron).  Lobelia  should  not  be 
employed  as  an  emetic,  as  it  produces  too 
much  nausea  and  depression.  When  so 
used  it  has  caused  death.  Lobeline  has 
been  used  in  the  treatment  of  spasmodic 
asthma.  Nunes  claims  that  it  is  free 
from  nauseant  or  irritant  properties  and 
can  be  used  hypodermically  in  doses  of 
Ve  t°  Vc  grain  for  children  and  1  to  6 
grains  for  adults.  Nunes  claims  a  cure 
in  eight  cases  of  tetanus  by  the  use  of 
lobeline. 

C.  Sumner  Witherstinb, 

Philadelphia. 

LOCKJAW.    See  Tetant  s. 

LOCOMOTOR  ATAXIA. 

Synonyms. — Posterior  spinal  sclerosis; 
tabes  dorsalis. 


LOCOMOTOR  ATAXIA.  SYMPTOMS. 


425 


Definition. — An  organic  disease  of  the 
periphero-central  sensory  nervons  system 
characterized  symptomatically  by  inco- 
ordination, sensory  and  trophic  disturb- 
ances; affections  of  special  nerves,  the 
optic  and  ocular  particularly;  and  in- 
volvement of  the  sphincters. 

Varieties.  —  In  its  classical  form  the 
symptom-complex  in  posterior  spinal 
sclerosis  is  exceedingly  constant.  There 
are  variations  in  the  clinico-pathological 
picture,  however,  which  justify  a  clas- 
sification into  at  least  three  types:  the 
common,  or  typical;  the  anomalous,  or 
atypical;  and  the  complicated.  .  In  typical 
cases  the  symptoms  point  to  a  primary 
disease  of  the  sensory  neurons  of  cer- 
tain areas  of  the  lower  dorsal  and  lum- 
bar cord  (common  type).  Occasionally, 
though  rarely,  the  primary  invasion  is  of 
the  upper  or  cervical  cord  (cervical  or 
superior  tabes),  and  in  still  others  the 
initial  symptom  may  be  an  optic  atrophy 
(amaurotic  tabes,  initial  optic-atrophy 
type).  The  predominance  and  persist- 
ence of  pain  in  certain  cases  has  served 
as  the  basis  for  a  so-called  neuralgic  type 
(tabes  dolorosa,  Eemak),  while  the  early 
development  of  general  or  pseudopara- 
plegic  muscular  weakness,  which  becomes 
rapidly  prominent,  affords  a  basis  for  the 
recognition  of  the  so-called  paralytic 
type.  True  motor  paralysis  is  not  an 
essential  part  of  tabes,  however,  except 
as  a  late  secondary  phenomenon.  Occur- 
ring  early,  it  indicates  the  existence  of  a 
complication.  Erratic  extensions  of  the 
disease  into  other  areas  of  the  cord  give 
rise  to  anomalous  symptoms,  which  are 
considered  elsewhere  under  the  head  of 
Complications,  The  terms  acute,  se- 
vere, and  mild  appear  in  the  literature 
of  the  subject,  but  are  unimportant  in 
significance. 

Symptoms.  —  The  symptomatic  study 
of  tabes  dorsalis  may  be  divided  into  at 


least  two  stages:  the  incipient,  or  pre- 
ataxic,  and  the  ataxic.  The  line  of  de- 
markation  is  so  indistinct  and  ill  defined 
clinically,  however,  as  scarcely  to  justify 
separate  consideration,  and  I  shall  there- 
fore describe  the  clinical  history  as  a 
whole,  reserving  for  a  separate  analysis 
of  individual  symptoms  the  question  of 
the  relation  of  such  symptoms  to  these 
two  stages. 

The  disease,  as  ordinarily  observed, 
begins  very  insidiously,  and  its  early 
progress  is  usually  slow.  The  first  sub- 
jective evidence  realized  by  the  patient 
may  be  a  sensation  of  numbness  or  other 
parsesthesise  (tingling,  burning,  "pins 
and  needles,"  etc.)  occurring  in  the  ex- 
tremities, or,  more  frequently,  attacks, 
occurring  paroxysmally  and  without 
warning,  of  sharp  stabbing  pains,  usu- 
ally in  the  legs,  but  without  constancy 
as  regards  distribution.  Slight  diminu- 
tion or,  rarely,  sudden  increase  in  sexual 
desire  or  power  may  be  noted  about  the 
same  time. 

Case  of  tabes  in  which  severe  lanci- 
nating pains  in  both  legs,  during  a  period 
of  twenty-five  years,  was  the  only  symp- 
tom of  the  latent  tabes,  while  in  another 
case  the  entire  series  of  symptoms  began 
with  incontinence  of  urine.  Hutchinson 
(Archives  of .  Surg.,  July,  '92). 

Four  hundred  cases  of  tabes  collected 
from  the  private  practice  of  Erb.  One 
hundred  of  these  cases  were  still  in  the 
initial  stages.  As  a  primary  symptom 
lancinating  pains  are  most  frequently 
mentioned, — 200  times  in  the  legs,  5 
times  in  the  back,  and  once  in  the  arms: 
Tabes  begins,  in  the  majority  of  instances 
(67  per  cent.),  with  lancinating  pains; 
nevertheless,  these  are  often  not  present 
alone  as  a  first  symptom,  but  are  accom- 
panied by  one  or  several  others.  On  the 
other  hand,  these  lancinating  pains  may 
exist  for  a  number  of  years  without  the 
disease's  manifesting  itself  in  any  other 
way.  The  frequency  of  the  single  symp- 
toms of  tabes  are  given  as  follows:  — 


426 


LOCOMOTOR  ATAXIA.  SYMPTOMS. 


Per- 
centage. 


Failure  of  patellar  reflexes  92.00 

Romberg's  symptom  88.75 

Lancinating  pains  88.25 

Vesical  disturbances  80.50 

Ataxia  of  the  legs  74.75 

Changes  in  pupillary  reaction  70.25 

Paresthesia  of  the  legs  04.50 

Weakness  of  the  legs  and  quick 

fatigue  62.25 

Absence  of  sexual  desire  58.25 

Changes  in  size  of  pupils  48.25 

Retarded  transmission  of  pain  36.50 

Hyperalgesia  of  the  legs  33.75 

Girdle  sensation  31.00 

Transitory  diplopia  26.50 

Hyperesthesia  of  the  legs     .23.25 

Ulnar  paresthesia  16.50 

Paralysis  of  ocular  muscles  16.00 

Atrophy  of  optic  nerve   6.75 

Persistence  of  pains  in  the  legs   6.00 

Crises   5.25 

Arthropathies   1.75 


Leimbach  (Deut.  Zeit.  f.  Nervenh.,  B. 
7,  Nos.  5,  6,  '95). 

Fatigue  from  exercise,  as  in  walking, 
dancing,  or  the  ordinary  occupation,  is 
greater  in  degree  and  occurs  more 
quickly  than  before. 

Case  in  which  there  was  absence  of  a 
sense  of  fatigue  in  a  tabetic  patient.  This 
patient  was  able  to  hold  both  arms  in  an 
horizontal  position  for  twenty-five  min- 
utes without  experiencing  the  slightest 
feeling  of  fatigue.  Frenkel  (Centralb.  f. 
Nervenh.,  Psych.,  u. '  gerich.  Psychop., 
.July  1,  '93). 

Transient  attacks  of  double  vision  may 
be  noted  with  or  without  ptosis.  The 
normal  action  of  the  bladder  and  some- 
times of  the  rectum  may  be  disturbed. 
Severe  attacks  of  rectal  neuralgia  some- 
times occur  quite  early  in  the  disease. 
Examination  at  this  time  will  develop 
the  fact  that  the  knee-jerks  are  either 
decidedly  diminished  in  activity  or  even 
abolished  (Westphal's  symptom).  Tests 
of  sensation  may  reveal  an  impaired 
tactile  perception  in  the  distribution  of 
the  ulnar  nerve  (Biernacki),  the  peroneal 


(Sarbo)  or  the  popliteal  space  (Bech- 
terew),  or  over  the  plantar  surfaces  of 
the  feet.  The  eyes,  on  examination,  will 
present  what  is  known  as  the  Argyll- 
Eobertson  pupil,  which  consists  in  a  loss 
of  the  reflex  to  light,  although  accom- 
modation to  distance  is  preserved.  The 
pupils  are  often  quite  early  found  ab- 
normally contracted,  sometimes  to  a  de- 
gree which  has  given  origin  to  the  term 
"pin-point"  pupil.  The  pupils  may  be 
unequal. 

The  disease  may  remain  practically 
stationary  at  this  stage  for  some  time, 
even  for  years  (Gray),  but  sooner  or  later 
symptoms  of  ataxia  supervene.  Ordi- 
narily the  ataxia  is  first  noticed  by  the 
patient  in  walking  at  night  or  along  a 
narrow  pathway  or  in  circumventing 
obstructions.  More  effort  is  required. 
Hitherto-automatic  action  in  walking, 
in  standing,  in  dancing,  and  in  other 
efforts  demands  more  and  more  con- 
scious attention  in  order  to  effect  proper 
co-ordination.  Quite  early  in  the  devel- 
opment of  the  ataxic  stage  the  patient 
will  present  the  Eomberg  symptom,  by 
which  is  meant  an  inability  to  stand 
without  swaying  or  falling  if  the  feet 
are  placed  close  together.  Minor  degrees 
of  this  variety  of  ataxia  can  sometimes 
be  demonstrated  only  with  the  patient's 
eyes  closed  or  by  having  the  patient  at- 
tempt to  stand  on  one  foot.  In  walking 
the  ataxia  is  manifest  in  the  increasing 
difficulty  with  which  the  patient  follows, 
heel  and  toe,  a  chalk  line  or  a  carpet- 
seam  or  crack  along  the  floor.  Here, 
again,  deprivation  of  the  co-ordinating 
assistance  of  vision  greatly  intensifies  the 
difficulty. 

Tabetic  patient  in  whom  the  disease 
first  showed  itself  as  arthritis  tabetics  in 
the  hip-joint.  Attention  called  to  the 
fact  that  the  most  varied  symptoms  may 
precede  the  entire  succession  of  usual 


LOCOMOTOR  ATAXIA.  SYMPTOMS. 


427 


symptoms.  Charcot  (Nouvelle  Icon,  de 
la  Salpetriere,  No.  3,  '92). 

[It  astonishes  me  that,  in  the  majority 
of  text-books,  a  pronounced,  and  also 
well-known,  initial  symptom  of  tabes  is 
not  mentioned, — i.e.,  the  inability  to  walk 
backward.  Obersteiner,  Assoc.  Ed., 
Annual,  '93.] 

One  of  the  earliest  disturbances  of  func- 
tion in  tabes  is  the  inability  to  walk 
backward.  Weiss  (Wiener  med.  Presse, 
Feb.  9,  '90). 

The  gait  becomes  characteristic;  the 
feet  are  kept  wide  apart  and  are  lifted 
unnecessarily  high,  are  brought  down  to 
the  floor  with  an  appearance  of  unusual 
and  unnecessary  force,  the  heel  striking 
first.  Charcot  is  quoted  as  stating  that 
he  often  made  the  diagnosis  of  locomotor 
ataxia  from  hearing  the  patient's  foot- 
falls as  he  approached  the  examination- 
room  and  before  having  seen  him  at  all. 
The  patient  will  often  state,  in  explana- 
tion of  his  defective  gait,  that  he  is 
losing  power  in  the  legs.  Attempts  at 
forced  flexion  or  extension,  the  patient 
n  sisting,  will  show,  however,  that  mus- 
cular power  is  intact.  The  ataxia  may 
extend — in  the  cervical  cases  it  begins — 
into  the  upper  extremities.  The  pianist 
loses  his  delicate  technique,  the  machin- 
ist his  dexterity.  Fastening  a  button, 
especially  when  not  in  the  field  of  vision, 
becomes  a  serious  problem.  If  asked  to 
touch  the  top  of  his  nose  with  the  tip  of 
his  linger  or  to  bring  his  outstretched 
arms  together  so  as  to  touch  the  tips  of 
the  right  and  left  forefingers,  the  eyes 
being  closed,  the  patient  will  almost  in- 
variably fail.  As  the  disease  progresses 
all  these  symptoms  become  intensified 
and  others  arc  added,  chiefly  sensory. 
The  patient  complains  of  a  feeling  of 
pressure  or  constriction  or  band  of 
numbness  around  the  waist  or  chest  or 
throat.  Various  disturbances  of  the 
viscera  may  develop.     Attacks  of  ap- 


parently causeless  vomiting,  of  gastric 
pain,  of  dyspnoea,  of  palpitation,  of  ves- 
ical or  rectal  tenesmus  occur  which  are 
known  as  crises.    Certain  trophic  altera- 

;  tions  in  the  skin,  hair,  and  nails  may 
be  present  or  the  teeth  may  fall  out 
gradually  and  painlessly.  The  joints, 
especially  the  knees  and  elbows,  some- 
times enlarge  suddenly,  as  a  rule,  with- 
out pain,  constituting  the  so-called  ta- 
betic arthropathies  of  Charcot.  The 
bones  become  easily  friable.  Abnormali- 
ties in  the  visual  apparatus  again  become 
conspicuous.    The  transient  strabismus 

"or  ptosis  of  the  earlier  stage  may  recur 
and  become  permanent.  The  optic  nerve 
presents  the  symptoms  of  atrophy,  and 
total  blindness  may  result.  The  optic 
nerve  may  be — and,  indeed,  often  is — ■ 
affected  quite  early  in  the  disease. 

Case  of  tabes  in  which  hemianopsia 
was  very  suddenly  developed  on  the  left 
side  without  any  other  symptoms.  F. 
Peterson  (Medical  News,  July  28,  '94). 

Among  the  cerebral  nerves,  those  in  re- 
lation with  the  eyes — that  is  to  say,  to 
its  muscles — are  most  frequently  affected 
in  tabes.  Wendell  Reber  (Lehigh  Valley 
Med.  Mag.,  June,  '95). 

Although  choked  disk  may  possibly 
occur  as  a  part  of  locomotor  ataxia,  it  is 
exceedingly  rare,  and  when  present  is 
nearly  always  due  to  syphilitic  lesions. 
Bernhardt  (Berliner  klin.  Woch.,  July 
15,  '95). 

All  forms  of  common  sensation  be- 
come impaired  in  varying  degrees  and 
different  localities.  The  pains  lessen  or 
disappear  and  an  analgesia  develops, 
which  may  be  absolute,  but  is  more  often 
partial  and  frequently  ataxic.  The  pa- 
tient, for  example,  if  pricked  on  the  left 
leg,  may  refer  the  painful  sensation  to 
the  right  (allochiria)  or  to  both  legs. 
This  phenomenon  is  sometimes  true, 
also,  of  tactile  and  temperature-  percep- 
1  tion.    Pain-conduction  may  be  retarded 


428 


LOCOMOTOR  ATAXIA.  SYMPTOMS. 


or  delayed.  Several  seconds  may  inter- 
vene between  the  actual  pin-prick  and 
the  patient's  conscious  appreciation  of  it. 

"Sensitive  tetanus''  described  as  a  pe- 
culiar disturbance  of  sensibility  occur- 
ring in  some  tabetic  patients;  a  number 
of  pricks  following  each  other,  not  too 
slowly,  are  experienced  by  the  patient  as 
a  continuous  pain,  and  not  as  separate 
pricks.  Marie  (Lecons  sur  les  Mai.  de  la 
Moelle,  '92). 

Careful  examination  of  sixty  tabetic 
patients,  with  special  regard  to  the  dis- 
turbances of  sensibility.  In  all  of  the 
cases  except  five,  which  were  tabo-para- 
lytic  throughout,  hyperesthesia  of  the 
trunk  was  a  constant  and  early  condi- 
tion. At  the  boundaries  of  the  hyperes- 
thesia and  between  the  lymphatic  zones 
there  is  generally  a  pronounced  hyper- 
algesia, particularly  as  regards  cold. 
Sensory-irritation  phenomena  are  fre- 
quent, but  not  constant.  Marked  anal- 
gesia of  the  ulnar  nerve  appears,  as  a 
rule  to  accompany  other  disturbances  in 
the  ulnar  region.  Max  Laehr  (Archiv  f. 
Psych,  u.  Nervenh.,  B.  27,  '95). 

[It  should  be  here  mentioned  that  the 
ulnar  symptom  is  also  frequently  met 
with  in  dementia  paralytica,  and  is  there- 
fore not  characteristic  of  tabes.  H. 
Orersteiner,  Assoc.  Ed.,  Annual,  '96.] 

Among  the  disturbances  of  sensibility 
in  locomotor  ataxia,  hyperesthesia  of  the 
trunk  appears  regularly,  and  usually 
early.  This  consists  for  a  long  time  only 
in  an  oversensitiveness  to  slight  touches, 
while  in  opposition  thereto  there  is 
usually  observed  in  the  beginning  on  the 
legs  a  diminution  of  the  pain-  and  post- 
ure- senses.  This  latter  appears  to  pre- 
cede somewhat  in  development  the  trunk- 
hyperesthesia,  which  in  the  beginning 
corresponds  usually  to  the  area  of  dis- 
tribution of  the  middle  thoracic  nerves. 
Symptoms  of  sensory  irritation  are  a  very 
frequent,  though  not  constant,  accom- 
paniment of  the  anesthesia.  A  marked 
ulnar-pressure  analgesia  with  other  dis- 
turbances of  sensation  in  the  ulnar 
region  appears  to  be  the  rule  in  tabes 
dorsalis.  LM.hr  (Archiv  f.  Psych.,  vol. 
xxvii,  part  3). 


Literature  of  'QG-W-'dS. 

Locality  of  anesthesia  studied  in  fifty 
cases  of  tabes,  ten  of  which  had  amau- 
rosis. Four  principal  types  found:  1. 
Thoracic,  present  in  forty  cases  either  as 
an  horizontal  zone  in  the  nipple-region  of 
either  side,  which  if  it  reaches  to  the 
axillary  line,  may  extend  to  the  inner 
aspect  of  the  arms;  the  nipple  bands  are 
united  anteriorly.  2.  In  the  upper  limbs 
anesthesia  may  be  limited  to  the  internal 
surfaces  of  the  arms,  or  may  extend  along 
the  inner  aspect  of  the  forearms  to  the 
little  finger.  3.  In  most  cases  of  tabes 
the  perineal,  anal,  and  genital  regions, 
especially  the  latter,  are  anesthetic,  and 
particularly  at  the  lower  part  of  the  scro- 
tum; this  is  often  found  in  the  early 
stage  of  the  disease.  When  present  it  is 
generally  found  in  other  parts  as  well, 
such  as  the  thorax  or  feet.  4.  In  the 
lower  limbs  the  position  of  the  anesthesia 
is  very  variable,  being  common  in  the 
plantar  and  dorsal  regions  of  the  foot,  the 
dorsum  of  the  toes,  the  outer  surface  of 
the  legs,  and  on  the  anterior  or  posterior 
surface  of  the  thighs.  Other  parts  of  the 
body  where  anesthesia  may  be  found  are 
the  epigastrium,  the  left  hypochondrium, 
and  the  larynx.  Cases  of  tabes  with 
amaurosis  often  have  normal  or  nearly 
normal  tactile  sensations.  Subjective 
symptoms  are  related  to  the  situation  of 
the  anesthesia;  to  the  first  group  there 
is  often  a  girdle  sensation,  to  the  second 
numbness  of  the  arms,  to  the  third 
troubles  of  micturition  and  impotence, 
and  to  the  fourth,  lightning  pains  and 
"pins  and  needles"  in  the  legs  and  feet. 
Marinesco  (Sem.  Med.,  Oct.  13,  '97). 

Case  of  locomotor  ataxia  in  a  man  who 
presented  all  the  ordinary  symptoms  of 
locomotor  ataxia:  but  in  addition  there 
was  complete  analgesia  over  the  whole 
body  except  on  and  around  the  mouth. 
The  analgesia  began  in  the  legs  and 
spread  upward.  C.  E.  Beevor  (Lancet, 
Jan.  22,  '98). 

The  muscular  sense  is  invariably  im- 
paired in  some  degree  and  in  nearly  all 
of  its  subdivisions  —  position,  weight, 
pressure,  etc.  If  the  eyes  are  closed  the 
patient  may  not  be  able  to  tell  whether 


LOCOMOTOR  ATAXIA.  SYMPTOMS. 


429 


a  given  muscle  or  set  of  muscles  is  being 
flexed  or  extended,  pronated  or  supinated, 
by  the  examiner.  If  two  wooden  globes, 
exactly  alike  in  appearance  and  size,  but 
differing  materially  in  weight,  are  placed  j 
in  the  hands  of  the  patient,  he  cannot 
distinguish  the  heavier  from  the  lighter. 
Pressing  unequally  with  the  hands  upon 
the  patient's  thighs  or  other  symmetrical 
parts  of  the  body,  he  is  unable  to  dis- 
tinguish the  inequality.  The  tempera- 
ture sense  may  be  also  affected  so  that 
variations  in  the  degree  of  contact  heat 
or  cold  are  not  appreciated.  Finally,  a 
condition  of  motor  helplessness  or  paresis 
may  be  superadded  to  the  sensory  dis- 
turbances. 

Case  of  tabes  in  which  peculiar  vaso- 
motor dilatations  occurred,  consisting 
of  a  cyanotic  appearance  of  the  face, 
neck,  and  fauces,  occasional  spontaneous 
ecchymoses  and  curious  local  sweatings. 
Audeoud  (Revue  Med.  de  la  Suisse  Rom., 
Sept.,  '90). 

Of  22  tabetic  patients,  2  found  in 
which  there  was  paralysis  of  the  pos- 
terior cricoarytenoid  muscles;  in  the 
others  no  motor  or  sensory  disturbances 
were  found  that  could  be  due  to  tabes. 
Drey  fuss  (Archiv  f.  Mikros.  Anat,,  B.  20, 
p.  154,  '90). 

Case  of  tabetic  patient  in  which  there 
was  total  paralysis  of  the  soft  palate,  also 
bilateral  paralysis  of  the  abductors  of  the 
vocal  cords.  Some  of  the  facial  muscles, 
the  masseters  and  the  temporals,  are 
much  wasted;  the  mouth  hangs  widely 
open,  owing  to  the  falling  of  the  lower 
jaw.   Semon  (Clinical  Jour.,  Jan.  14,  '93). 

Case  of  tabes  in  which  there  was  tempo- 
rarily present  the  rare  symptom  of  labio- 
glosso-laryngoal  paralysis,  resulting  in 
aphonia;  the  impossibility  of  pronoun- 
cing a  syllable,  even  softly;  and  move- 
ments  of  Iho  tongue  slow  and  restricted. 
Lepine  (Lyon  Med.,  Feb.  18,  '94). 

Case  of  tabes  with  bilateral  paralysis 
of  the  abductors  in  the  larynx.  Fr. 
Hawkins  (Lancet,  June  1,  '95). 


Literature  of  '96-'97-'98. 

Case  of  bilateral  abductor  paralysis  of 
the  larynx  accompanying  tabes  dorsalis. 
There  is  immobility  of  the  vocal  cords, 
which  are  closely  approximated,  leaving 
only  a  very  narrow  slit  for  respiration. 
The  voice  is  well  preserved;  although 
somewhat  monotonous,  it  is  strong  and 
clear.  E.  L.  Vansant  (Phila.  Med.  Jour., 
Feb.  19,  '98). 

Several  variations  in  the  picture  de- 
scribed, particularly  as  regards  the  order 
of  precedence  in  symptoms,  may  occur. 
The  disease  may  begin  with  an  initial 
ataxia;  it  may  begin  with  an  optic  neu- 
ritis or  atrophy.  In  rare  instances  the 
earlier  symptoms  are  referable  to  lesions 
in  the  cervical  cord,  the  upper  and  not 
the  lower  extremities  being  affected  first 
symptomatically.  Such  cases  are  known 
as  cervical  and  sometimes  as  superior  or 
descending  tabes,  though  the  two  latter 
terms  have  also  been  applied  to  general 
paresis  with  secondary  posterior  spinal 
sclerosis.  Painful  sensory  phenomena 
are  much  more  marked  and  persistent 
and  wide-spread  in  some  cases  than  in 
others.  The  shooting,  stabbing,  grind- 
ing pains  in  the  legs,  the  rectal  pains, 
the  trigeminal  pains,  the  painful  crises, 
may  be  all  extreme  and  give  rise  when 
.present  to  what  has  been  termed  the 
neuralgic  type.  If  the  disease  develops 
within  a  year  or  two  after  primary  syph- 
ilis, the  symptom-picture  takes  on  more 
distinctly  the  bizarre  characteristics  of 
exudative  nervous  syphilis. 

Under  the  term  "acute  ataxia"  are 
grouped  cases  in  which  the  onset  of  the 
ataxia  is  sudden,  of  rapid  course,  some- 
times quickly  fatal,  though  often  ending 
in  recovery,  being  mostly  cases  of  ataxia 
occurring  after  some  acute  disease,  rarely 
arising  spontaneously.  The  central  (cere- 
bral) form  is  characterized  by  acute 
ataxia,  without  sensory  disturbances, 
scanning  speech,  resembling  the  speech- 
disturbances  of  multiple  sclerosis.  The 


430 


LOCOMOTOR  ATAXIA.  SYMPTOMS. 


intelligence  may  or  may  not  be  affected. 
Recovery  occurs  in  some  cases  after  a  few 
weeks;  in  others  it  becomes  chronic  and 
stationary,  death  occurring  from  some 
intercurrent  disease.  The  second  form — 
sensory  ataxia — is  due  to  multiple  neu- 
ritis. It  is  differentiated  from  the  ataxia 
tabes  by  its  acute  or  subacute  onset,  by 
frequent  termination  in  recovery,  and  the 
return  of  the  knee-jerks.  The  sensory 
symptoms  usually  present  are:  pain, 
numbness,  hypersesthesia,  and  anaesthesia. 
Disturbances  of  speech  are  absent.  It 
follows  exposure  to  cold  and  moisture, 
acute  fevers,  alcoholism,  lead  and  arsen- 
ical poisoning,  and  possibly  syphilis. 
Leyden  (Zeit.  f.  klin.  Med.,  B.  18.  H.  5,  6, 
'91). 

Symptomatic  Analysis.  —  The  Re- 
flexes.— One  of  the  earliest — possibly  the 
earliest  demonstrable — symptom  of  loco- 
motor ataxia  is  a  diminution  in  activity 
of  the  patellar-tendon  reflex.  This  dim- 
inution may  be  first  unequal  on  the 
two  sides,  but,  as  the  disease  progresses, 
both  knee-jerks  are  affected  and  event- 
ually lost  (Westphal's  symptom).  So 
constant  is  this  symptom  as  to  have 
been  considered  pathognomonic  by  some 
writers  (Buzzard).  Absence  of  the  knee- 
jerks  may  exist  in  persons  who  are  other- 
wise healthy,  although  such  instances 
are  not  at  all  common.  The  integrity 
or  abnormality  of  the  knee-reflex  may  be 
elicited  by  various  methods,  the  simplest 
of  which  is  to  have  the  patient  "cross" 
the  leg  carelessly,  when,  with  the  side  of 
the  extended  hand  or  a  percussion-ham- 
mer, a  sharp  tap  over  the  tense  patellar 
tendon  will  ordinarily  demonstrate,  in 
the  resultant  jerk  of  the  leg,  the  normal 
or  exaggerated  presence  of  the  tendon- 
reflex,  or,  in  the  absence  of  response,  the 
loss  of  such  reflex  action.  Such  a  test, 
however,  is  crude,  and  should  not  lie 
considered  final  unless  practiced  in  con- 
junction with  some  one  of  the  methods 
of  sensory  or  mental  reinforcement,  the 
simplest  of  which    is   that    known  as 


Jendrassik's.  This  consists  in  having 
the  patient  grasp  the  hands  tightly  and 
look  up  at  the  ceiling,  or  at  least  away 
from  the  field  of  examination,  as  the 
tendon  is  struck.  While  abolition  of  the 
knee-jerk  is  exceedingly  constant  as  a 
part  of  the  symptom-picture,  occasional 
examples  of  the  disease  have  been  noted 
in  which  the  reflex  was  preserved  and 
remained  intact.  Westphal  himself,  as 
well  as  Pick,  Krauss,  Lehman,  and,  more 
recently,  Achord  and  Levi  (La  Med. 
Mod.,  9,  p.  167,  ?98)  have  reported  such 
instances,  the  explanation  being  found 
in  the  non-involvement,  by  the  disease- 
process,  of  the  zone  of  entry  (wurzell 
eintritt)  of  the  corresponding  posterior 
roots.  The  occurrence  of  hemiplegia  in 
a  tabetic  patient  may  result  in  the  re- 
turn of  the  knee-jerk,  which  may  even 
be  exaggerated  in  such  cases. 

The  studies  of  Sherrington  upon  the 
phenomena  connected  with  the  patellar- 
tendon  reflex  are  of  especial  interest  in 
this  connection. 

[Mills,  following  the  observations  of 
Babinski  (Le  Prog.  Med.,  Oct.  29,  '98)  as 
to  the  significance  of  the  tendo-Aehillis 
jerk  in  tabes,  examined  100  cases  of 
nervous  disease,  28  of  which  were 
tabes,  with  regard  to  this  point.  Of 
the  non-tabetic  cases,  it  is  sufficient  to 
state  that  he  found  this  reflex  present 
and  equal  in  all  of  the  72  patients.  Of 
the  28  tabetics  only  3  exhibited  the  tendo- 
Aehillis  jerk  and  in  all  three  the  knee- 
jerk  was  also  present.  In  one  the  phe- 
nomenon was  well  marked,  in  another 
slight  and  in  the  third  present  only  on 
one  side.  Mills  thinks  that  an  investiga- 
tion of  the  tendo-Aehillis  jerk  may  prove 
of  diagnostic  importance  in  removing  the 
element  of  doubt  present  in  the  cases  of 
tabes  occasionally  encountered  in  which 
the  patellar-tendon  reflex  is  preserved, 
such  cases  usually  showing  alteration  of 
the  Achilles-tendon  jerk.  W.  B.  PRITCH- 
ABD.] 

Tn  early  tabes  the  cutaneous  and  super- 


LOCOMOTOR  ATAXIA.  SYMPTOMS. 


43.  t 


ficial  reflexes  are  preserved  and  may  be 
exaggerated:  a  fact  of  some  diagnostic 
significance,  in  the  opinion  of  Bechterew 
(Revue  de  Psych.,  No.  8,  ;97).  In  the 
late  disease  these  also  are  lost. 

Two  early  symptoms  are:  1.  The  epi- 
gastric reflex  appears  more  pronounced; 
the  abdominal  muscles  contract  when  the 
finger-nail  is  passed  over  the  skin  of  the 
abdomen;  this  epigastric  reflex  is  un- 
doubtedly, to  a  certain  degree,  antago- 
nistic to  the  patellar  reflex.  When  in 
tabes  the  abdominal  retiex  is  more  pro- 
nounced, the  patellar  reflex  is  lessened.  2. 
The  second  symptom,  which  is  already 
noticeable  at  a  very  early  stage,  is  the  in- 
capacity to  raise  one's  self  on  tiptoes,  the 
eyes  being  closed.  Ott,  Rosenbach  (Cen- 
tralb.  f.  Nervenh.,  etc.,  Apr.,  '92). 

Literature  of  '96-'97-'98. 

Twenty-six  cases  of  tabes  investigated 
in  which  the  patellar  and  ankle  reflexes 
were  absent  in  all  the  cases.  In  11  pa- 
tients in  the  preataxic  stage,  the  abdomi- 
nal reflexes  were  strongly  increased  on 
both  sides  in  10  and  well  marked  in  1; 
of  10  cases  in  the  ataxic  stage  the  ab- 
dominal reflexes  were  much  increased  in 
3,  well  marked  in  5,  very  slow  in  1,  and 
not  present  in  1 ;  of  5  cases  in  the  para- 
lytic stage,  the  abdominal  reflexes  were 
completely  absent  in  4  and  in  1  case  were 
increased.  Ostankow  (Neurol.  Centralb., 
p.  140,  '08). 

The  earliest,  most  constant,  and  ob- 
trusive symptoms  of  locomotor  ataxia  in 
its  early  stage  are:  absent  knee-jerks, 
shooting  or  lightning-like  pains,  and  loss 
of  iritic  reflex.  J.  T.  Eskridge  (Charlotte 
Med.  Jour.,  Dec,  '98). 

Pupillary  Symptoms.  —  Fixed  pupil- 
lary contraction  (spinal  myosis);  a  loss, 
abruptly,  or  gradually  progressive,  of  the 
reflex  action  to  light;  accommodation  to 
distance  and  in  convergence  being  pre- 
served (reflex  iridoplegia,  Argyll-Robert- 
son pupil)  with  loss  of  the  sympathetic 
skin -re  (lex.  are  the  more  constant  and 
characteristic  pupillary  abnormalities  in 
tabes.    Both  eyes  are  usually  affected 


and  to  about  the  same  degree.  The 
iridoplegia  may  be  unilateral,  however; 
and  the  two  pupils  may  be  unequally 
contracted  or  one  only  may  be  abnor- 
mally small.  Permanent  mydriasis  or 
dilatation  has  been  rarely  observed. 

The  Argyll-Robertson  pupil  is,  per- 
haps, the  most  constant  and  characteris- 
tic symptom  in  posterior  spinal  sclerosis. 
It  is  also  an  early  symptom  invariably, 
and  in  combination  with  abolished  knee- 
jerks  affords  sufficient  data  for  diagnosis 
even  in  the  absence  of  all  other  symp- 
toms. In  late  tabes  the  action  of  the 
pupils  in  accommodation  is  also  lost. 

Literature  of  '96-'97-'98. 

Case  of  man  suffering  from  tabes  dor- 
salis,  who,  when  examined  in  1896,  had 
the  characteristic  signs  of  the  disease, 
with  the  exception  that  the  pupils  re- 
acted both  to  light  and  in  accommoda- 
tion. Four  months  later  the  symptoms 
were  still  more  pronounced,  and  the 
pupils  failed  to  react  either  to  light  or  in 
accommodation.  This  condition  con- 
tinued for  nearly  a  year,  when  it  was 
found  that  the  pupils  reacted  well  to 
light  and  continued  so  to  react  for  the 
remainder  of  the  period  during  which  the 
patient  was  under  observation.  The  case 
illustrates  improvement  in  the  pupillary 
symptoms,  while  the  general  symptoms 
grew  worse.  Treupel  (Munchener  med. 
Woch.,  Aug.  30,  '98). 

Two  cases  of  intermittent  Argyll- 
Robertson  pupil  in  tabes  dorsalis.  Both 
patients  were  women  38  years  of  age.  In 
both  cases  there  were  evidences  of  syphi- 
lis, and  the  symptoms  of  tabes  were  plain. 
The  pupil  reflexes  varied  under  continued 
observation  and  notwithstanding  steady 
progress  of  the  disease.  Eichhorst  (Deut. 
med.  Woch.,  No.  23,  '98). 

The  lesion  in  Argyll-Robertson  pupil 
is  probably  in  the  fibres  which  pass  from 
the  proximal  end  of  the  optic  nerve  to 
the  oculomotor  nerve,  according  to  de 
Schweinitz,  who  quotes  Turner,  how- 
ever, as  believing  that  a  single  lesion  in 


432 


LOCOMOTOR  ATAXIA.  SYMPTOMS. 


the  forepart  of  the  oculomotor  nuclei  in 
the  Sylvian  gray  as  the  cause  of  both 
myosis  and  reflex  iridoplegia. 

Optic  Atrophy.  —  This  symptom  may 
occur  at  any  stage,  though  usually  it  is 
present  in  early  tabes.  It  has  been  found 
in  from  10  to  35  per  cent,  of  cases  ac- 
cording to  the  observer.  Bergur  found 
it  present  in  44  of  109  cases.  Disturb- 
ances of  color-sense  and  contraction  of 
the  visual  field  are  associated  phenom- 
ena. The  progress  of  the  atrophy  is 
usually  slow,  and  remissions  may  occur. 
Blindness  ensues  in  from  three  to  five 
years.  The  ataxia  and  also  the  painful 
sensory  symptoms  diminish  upon  the 
onset  of  blindness,  as  a  rule  (amaurotic 
tabes).  The  left  eye  is  said  to  be  at- 
tacked oftener  than  the  right.  Both  eyes 
are  usually  involved,  however. 

Five  cases  of  tabes  in  which  atrophy 
of  the  optic  nerve  preceded  the  usual 
symptoms  of  tabes  during  a  long  period 
(up  to  twenty-five  years).  Howell  Persh- 
ing (Med.  News,  Mar.  26,  '92). 

The  onset  of  optic  neuritis  in  the  early 
stage  of  tabes  is  followed  by  improve- 
ment in  other  symptoms,  and  retards  or 
arrests  the  further  course  of  the  disease. 
Martin  (Neurol.  Centralb.,  Oct.  1,  '90). 

The  specific  motor  symptoms  in  tabes 
begin  to  disappear  as  soon  as  atrophy  of 
the  optic  nerve  sets  in.  Benedikt  (La 
Med.  Mod.,  Mar.  20,  '95). 

Literature  of  '96-'97-'98. 

In  about  75  per  cent,  of  the  cases  of 
tabes,  in  which  optic  atrophy  is  an  early 
symptom,  some  of  the  other  tabetic  symp- 
toms may  be  late  in  appearing  or  may 
not  develop  at  all.  This  is  especially  the 
case  in  respect  to  the  lightning  pains  and 
the  inco-ordination  of  movement.  The 
loss  of  knee-jerk  in  such  cases  is  very 
constant. 

The  most  distressing  symptoms  may 
develop  simultaneously  with  or  immedi- 
ately succeed  the  blindness. 

The  association  with  the  optic  atrophy 
of  oculomotor  palsies  is  without  prognos- 


tic significance.  Pearce  Bailey  (Med. 
Rec,  Nov.  14,  '96). 

Ophthalmoscopically  the  optic  atrophy 
of  posterior  spinal  sclerosis  presents  the 
appearance  of  primary  degenerative  at- 
rophy in  contrast  to  the  appearance  in 
that  form  which  follows  neuritis. 

Ocular-Muscle  Palsies.  —  One  of  the 
first  symptoms  in  locomotor  ataxia  may 
be  an  attack  of  double  vision  with  or 
without  ptosis.  Occurring  in  the  early 
stages  of  the  disease,  t  such  attacks  are 
usually  of  abrupt  onset  and  transitory 
duration,  disappearing  completely  in  a 
few  days  or  weeks.  Well-marked  strabis- 
mus, most  commonly  of  the  variety  due 
to  sixth-nerve  involvement,  may  be  pres- 
ent, and,  if  an  early  symptom,  is  equally 
abrupt  in  onset  and  transient  in  dura- 
tion. Mobius  believes  that  sudden  pain- 
less ocular  palsies  in  an  adult  are  almost 
pathognomonic  of  tabes.  They  are  cer- 
tainly exceedingly  suggestive.  Ptosis, 
more  or  less  decided,  is  frequently  noted 
in  late  stages  of  posterior  spinal  sclerosis. 
Such  ptosis  is  usually  of  slow  progressive 
development  and  remains  permanent. 
This  is  true,  also,  of  strabismus.  Oph- 
thalmoplegia, both  external  and  internal, 
has  been  sometimes  observed,  though 
with  decided  infrequency. 

Interesting  case  of  tabes  with  cranial- 
nerve  palsies  (third,  fourth,  fifth,  and 
sixth),  supposed  to  be  of  nuclear  origin, 
and  with  muscular  atrophies  in  the  upper 
and  lower  extremities.  The  case  had  been 
reported  at  an  earlier  stage  by  Seguin  as 
one  of  external  and  internal  ophthalmo- 
plegia, with  incipient  tabes.  Peterson 
(Jour,  of  Nerv.  and  Mental  Dis.,  July, 
'90). 

Case  of  chronic  progressive  paralysis 
of  the  ocular  muscles  in  a  patient  suffer- 
ing with  tabes  and  general  paralysis  of 
the  insane.  Boedeker  (Centralb.  f.  Ner- 
vonh..  etc.,  Juno.  '91). 

Patient  in  whom  the  symptom  of  pa- 
ralysis of  the  eve-muscles  occurred  in  the 


LOCOMOTOR  ATAXIA.    SYMPTOMS.  433 


first  stage  of  tabes;  all  the  external 
muscles  innervated  by  the  nervi  oculomo 
torius  became  paralyzed  later  on.  Rendu 
(Le  Bull.  Med.,  Mar.  16,  '92). 

Transient  ptosis,  or  diplegia,  Argyll- 
Robertson  pupil,  incipient  optic-nerve 
atrophy,  associated  in  an  individual  past 
middle  life,  of  inherited  neurotic  tend- 
ency, are  strong  presumptive  evidence  of 
the  first  stage  of  locomotor  ataxia.  Han- 
sell  (Jour.  Nerv.  and  Mental  Dis.,  Apr., 
'93). 

Slight  paresis  of  the  ocular  muscles, 
particularly  in  the  early  stages  of  tabes, 
even  though  of  temporary  duration,  is  of 
very  frequent  occurrence,  though  often 
overlooked.  G.  Rummo  (Lezioni  di  Clin. 
Med.,  894). 

Ataxia.  —  The  disease  may  manifest 
itself  first  in  an  ataxia  of  gait  or  station 
(acute  locomotor  ataxia).  Usually,  how- 
ever, as  has  been  already  stated,  various 
sensory  and  other  symptoms  prominently 
precede  the  ataxia,  disturbances  of  co- 
ordination being  essentially  dependent 
upon  impaired  centripetal  or  sensory  im- 
pressions. Loss  or  defect  of  muscular 
sensibility  and  particularly  of  position- 
sense  is  the  dominant  factor  responsible 
for  the  ataxic  gait  and  the  inco-ordina- 
tion  of  the  upper  extremities.  The  phe- 
nomenon known  as  Eomberg's  symptom 
is  probably  due  to  the  associated  involve- 
ment of  both  tactile  and  muscular  sensi- 
bility. Leyden's  experimental  induction 
of  this  symptom  by  freezing  (anaesthe- 
tizing)  the  soles  of  the  feet  with  ether- 
spray  demonstrates  at  least  some  par- 
ticipation of  the  tactile  sense  in  the 
production  of  this  symptom.  Helpless- 
ness from  ataxia  should  be,  it  is  scarcely 
necessary  to  state,  carefully  distinguished 
from  helplessness  due  to  true  motor  pa- 
ralysis or  paresis. 

Romberg's  symptom  is  caused  solely  by 
a  feeling  of  dizziness  when  the  eyes  are 
closed.  Grasset  ( Archives  do  Neurol.,  vol. 
xxv,  '93). 


Literature  of  '96-'97-'98. 

Case  of  locomotor  ataxia  in  which,  not- 
withstanding the  fact  that  the  patient 
was  perfectly  blind,  he  could  stand  with 
his  feet  close  together  with  but  little 
swaying.  The  moment  he  closed  his  eyes, 
however,  he  swayed  violently,  and  would 
fall  over  if  not  supported.  F.  F.  Ward 
(Med.  Rec,  Oct.  8,  '98). 

Tabetic  Crises. — These  consist  of  at- 
tacks, occurring  suddenly,  without  as- 
signable cause  and  ending  quite  abruptly, 
as  a  rule,  which  may  simulate  symptom- 
atically  ordinary  attacks  of  gastric,  intes- 
tinal, nephritic,  vesical,  or  hepatic  colic. 
Gastric  crises  are  most  common.  The 
patient  is  suddenly  seized  with  excruciat- 
ing gastric  or  abdominal  pain,  which  is 
usually  accompanied  with  violent  retch- 
ing and  vomiting.  The  attack  may  be 
prolonged  for  two  or  three  days  or  it  may 
end  after  a  single  paroxysm  lasting  a 
few  minutes,  recurring  at  varying  inter- 
vals from  a  week  to  several  months. 
Except  from  malnutrition,  such  attacks 
are  not  dangerous. 

Case  of  tabetic  patient  in  whom,  simul- 
taneously with  the  gastric  crises,  pro- 
nounced acuteness  of  the  sense  of  smell 
is  present.  Negro  (Rev.  Clin,  de  los 
Hosp.,  Mar.  8,  '94). 

Case  of  man  in  the  paralytic  and 
atrophic  stage  of  tabes,  whose  gastroin- 
testinal crises  were  accompanied  or  ush- 
ered in  by  profuse  sialorrhcea,  beginning 
suddenly,  often  at  night,  and  nearly 
choking  the  patient.  Gastric  crises  would 
follow,  then  intestinal  crises,  sometimes 
accompanied  by  genito-urinary  symp- 
toms, the  attacks  lasting  from  three  to 
twelve  days.  Girode  (La  France  Med.. 
Feb.  19,  '89). 

Three  cases  of  tabes  in  which  gastric 
crises  were  the  first  symptom,  and.  later 
on,  remained  the  dominant  one.  There 
w  as  a  const  ;i 71 1  lack  of  hydrochloric  acid 
both  during  the  crises  and  in  the  inter- 
vals.  L.  Wolff  (Lakare.  Forhand.,  '95). 

I  It  is  striking  thai  gastric  crises  are 
very  frequently  combined  with  laryngeal 


434  LOCOMOTOR  ATAXIA.  SYMPTOMS. 


symptoms  and  are  seldom  absent  when 
arthropathies  are  present.  H.  Ober- 
steiner,  Assoc.  Ed.,  Annual,  '96.] 

When,  however,  the  heart's  action  or 
the  functions  of  respiration  are  involved, 
the  danger  is  much  greater,  fatal  results 
having  been  recorded  in  both  cardiac  and 
laryngeal  crises.  Both  varieties,  fortu- 
nately, are  rare.  The  symptoms  in  laryn- 
geal crises  are  not  unlike  those  of  laryn- 
gismus stridulus:  dry,  violent  cough, 
with  spasmodic  inspiration  and  marked 
dyspnoea  and  at  times  loss  of  conscious- 
ness. Burning  pains  in  the  neck  and 
shoulder-muscles  sometimes  attend  these 
laryngeal  crises. 

Two  cases  of  tabes:  one  with  laryngeal 
crisis,  the  other  with  hypersesthesia  to 
light  and  sound.  Charcot  (La  Sem.  Med., 
June  4,  '90). 

Case  of  tabes  with  laryngeal  crisis,  in 
which  the  post-mortem  histological  ex- 
amination revealed,  besides  the  usual 
characteristic  spinal  lesion  of  tabes,  a  bi- 
lateral chronic  diffuse  neuritis  of  the 
vagus  and  spinal  accessory  roots,  but 
without  involvement  of  the  nuclei  of 
these  nerves.  Van  Gieson  (Jour,  of  Nerv. 
and  Mental  Dis.,  July,  '90). 

In  122  cases  of  tabes  laryngeal  disturb- 
ances referable  to  tabes  were  found  in  17 
cases.  In  4  cases  laryngeal  crises  were 
observed.   Bohne  (Inaug.  Dissert.,  '95). 

Case  with  pharyngeal  crises.  Patient 
was  a  man  who  had  become  exceedingly 
emaciated,  the  slightest  attempt  at  tak- 
ing nourishment  causing  severe  contrac- 
tions of  the  pharynx.  After  a  single 
treatment  by  suspension,  this  condition 
entirely  disappeared.  Courmont  (Revue 
de  Med.,  Sept.,  '94). 

Two  cases  of  severe  pharyngeal  crises, 
one  of  the  patients  dying  during  such  an 
attack.  Moreira  (Pharingismo  Tabetico, 
'94). 

Attention  called  to  peculiar  pains  in 
certain  glands  which  may  occur  in  tabes 
from  time  to  time.  Several  hours  before 
the  onset  of  the  attack  the  patient  com- 
plains of  a  peculiar,  uncomfortable  sensa- 
tion in  the  region  in  question,  and  sud- 
denly very  severe  pain  is  felt,  lasting  sev- 


eral hours;  the  glands  quickly  swell,  and 
the  skin  becomes  reddened;  the  swelling 
and  redness  slowly  disappear  after  a  few 
days.   Wood  (La  Sem.  Med.,  No.  7,  '93). 

Cardiac  Crises. —  Cardiac  crises  re- 
semble symptomatically  attacks  of  an- 
gina pectoris.  There  may  be  actual  dis- 
ease of  the  heart  of  trophic  origin.  A 
rapid  pulse — 100  to  120 — was  frequently 
noted  in  Charcot's  cases  without  asso- 
ciated cardiac  crises. 

Case  of  tabetic  patient  who  was  sub- 
ject to  attacks  of  tachycardia  with  ac- 
celerated breathing  without  dyspnoea ; 
these  attacks  occurred  several  times  a 
day  and  lasted  about  half  an  hour.  They 
were  cardiac  crises.  Zenner  (Ohio  Med. 
Jour.,  Dec,  '91). 

Literature  of  '96-'97-'98. 

In  138  cases  of  locomotor  ataxia  12 — 
or  8.76  per  cent. — were  complicated  with 
valvular  disease.  In  9  of  the  cases — or 
6.5  per  cent. — the  lesion  was  aortic  dis- 
ease. The  valvular  affection  generally 
first  showed  itself  after  the  tabetic  symp- 
toms were  well  advanced.  Five  cases 
were  undoubtedly  syphilitic,  and  6  prob- 
ably so,  but  in  1  case  there  was  no  evi- 
dence of  the  disease.  In  2  cases  aortic 
aneurism  was  associated  with  the  valvu- 
litis. Rheumatism  was  only  noted  in  2 
of  the  12  cases.  As  symptoms  are  not 
always  present,  the  aortic  disease  may  be 
overlooked.  The  association  of  the  two 
diseases  is  probably  the  result  of  syphilis, 
which  is  an  important  cause,  both  of 
tabes  and  of  cardiac  disease.  Ruge  and 
Hutter  (Berliner  klin.  YVoch.,  Aug.  30, 
'97). 

The  crises  of  tabes  possess  a  localizing 
pathological  value  quite  analogous  to 
that  of  the  aura  or  signal  symptom  in  epi- 
lepsy, pointing  to  an  invasion  and  irrita- 
tive degeneration  of  the  vagus-nuclei  or 
fibres,  or  to  fibres  elsewhere  that  are  in 
physiological  relation  to  the  functions 
involved  in  the  symptoms.  Crises  are 
among  the  earlier  clinical  phenomena 
usually,  but  they  may  persist  for  many 


LOCOMOTOR  ATAXIA. 


years.  They  often  disappear  with  the 
lancinating  pains,  with  which  they  are 
intimately  associated,  as  the  disease  ad- 
vances. 

A  constant  secretion  of  tears  is  some- 
times met  with  in  tabes,  while  in  other 
cases  there  are  actual  tear-crises,  similar 
to  gastric  crises.  Panas  (La  Presse  Med., 
May  4,  '94). 

Literature  of  '96-'97  '98. 

Case  of  a  waiter,  41  years  old,  who 
suffers  from  locomotor  ataxia  and  begin- 
ning paralytic  dementia.  He  has  fre- 
quent and  sudden  attacks  of  violent  burn- 
ing pain  in  both  eyes  and  the  peribulbar 
tissues,  accompanied  by  spastic  myosis, 
epiphora,  and  chemotic  swelling  of  the 
conjunctivas.  There  also  is  much  hyper- 
esthesia in  the  eyelids,  which  makes 
further  examination  of  the  eyes  impos- 
sible. These  attacks  last  from  two  to 
three  hours;  an  hour  after  the  attack 
the  eyes  are  practically  normal.  These 
attacks  considered  to  be  true  ocular 
crises — attacks  of  neuralgia  of  the  ciliary 
nerves,  and  irritation  of  the  fifth  nerve. 
Pel  (Berliner  klin.  Woch.,  No.  2,  Jan.  10, 
'98). 

Sensory  Symptoms.  —  The  defects  or 
abolition  in  the  several  forms  of  common 
sensations  have  been  sufficiently  de- 
scribed in  the  clinical  history  of  which 
they  form  an  exceedingly  constant  and 
essential  part.  Among  the  less  fre- 
quently noted  sensory  phenomena  are 
analgesia  of  the  testicle  and  anaesthesia 
in  the  distribution  of  the  fifth  nerve, 
especially  over  the  mucous  membranes 
of  the  mouth  and  eyelids. 

Frequent  changes  in  the  pharynx  and 
larynx  of  3C  tabetic  patients.  There  were 
sensory  disorders  of  the  pharynx  in  14,  of 
the  larynx  in  L0,  paresis  of  the  adduc- 
tors in  10.  immobility  of  the  cords  in  4, 
diminished  power  of  adduction  in  8,  and 
ataxic  movements  of  the  tongue  in  !). 
The  pharyngo-laryngeal  disorders  were 
more  intense  in  the  advanced  stages  of 
tabes.  Marini  (Archiv  f.  Psych,  u. 
Nervenk.,  B.  21,  H.  1,  '90). 


SYMPTOMS.  435 

Case  presenting  the  typical  signs  of 
tabes  of  many  years'  duration,  in  which 
lancinating  pains  occurred  in  the  left  side 
of  the  face,  and  in  which  the  pharynx 
was  insensible  to  the  touch,  and  the 
uvula  anaesthetic  and  paretic.  Speech 
and  deglutition,  however,  were  not 
affected.  Schnell  (Marseille-med.,  Oct. 
15,  '91). 

Case  of  male  tabetic  patient,  with  ul- 
cerations both  in  the  region  of  the  right 
upper  and  the  left  lower  jaw.  These  ul- 
cerations are  to  be  referred  to  a  tabetic 
neuritis  of  the  trigeminus,  since  complete 
anaesthesia  of  the  face  and  mucous  mem- 
brane of  the  mouth  was  present.  Hudelo 
(Bull,  de  la  Soc.  Franchise  de  Derm,  et 
de  Syphil.,  May  18,  '93). 

Pitres  found  analgesia  of  the  testicle 
in  75  per  cent,  of  his  cases.  It  varies  in 
degree  from  time  to  time  and  may  dis- 
appear entirely  to  return,  however,  after 
varying  intervals.  Its  disappearance  has 
been  noted  as  occurring  simultaneously 
with  a  return  of  sexual  power.  While 
pain  is  a  very  common  symptom  in  many 
forms  of  nervous  disease,  the  sharp  stab- 
bing vagabond  pains  which  occur  in  loco- 
motor ataxia  are  so  distinctive  in  char- 
acter as  to  be  unique.  No  two  patients 
will,  perhaps,  describe  them  in  the  same 
way,  and  yet  their  identical  character  is 
at  once  evident  from  the  description  of 
a  dozen  or  more  patients.  They  are 
often  worse  at  night  and  under  baro- 
metric conditions  of  excessive  humidity 
presaging  a  storm.  Tabetics  are  often, 
indeed,  quite  reliable  weather-prophets. 

Of  34  tabetics,  8  had  normal  testicles, 
10  were  hyperalgesic,  and  16  analgesic; 
of  the  latter  4  had  atrophy  of  the  testicle. 
Pitres's  sign  considered  of  great  value. 
It  consists  in  the  loss  or  diminution  of 
the  characteristic  pain  produced  in  the 
normal  testicle  by  compression.  Bitot 
and  Sabrazes  (Jour,  de  Med.  de  Bordeaux. 
Feb.  2,  '90). 

Among  35  tabetic  patients,  both  tes- 
ticles were  normal  in  11,  in  4  there  was 
bilateral  analgesia;   in  4  bilateral  hyper- 


436 


LOCOMOTOR  ATAXIA.  SYMPTOMS. 


sesthesia;  in  2  there  was  atrophy  of  both 
testicles;  in  2  atrophy  of  only  the  right 
testicle;  in  7  diminished  sensibility  of 
the  penis;  and  in  11  impotence.  Anal- 
gesia of  the  testicles  and  failure  of  the 
cremaster  reflex  are  entirely  independent 
of  each  other.  In  15  patients  inconti- 
nence was  found,  in  3  retention,  and  in  1 
ischuria  paradoxa  (constant  dropping  of 
urine  from  a  full  bladder).  B.  A.  Tatart- 
scheff  (Die  Urogenital  Storungen  bei 
Tabes  Dorsalis,  '92). 

Trophic  Symptoms. — Some  degree  or 
variety  of  trophic  disturbance  is  usually 
manifest  at  some  time  during  the  prog- 
ress of  the  disease.  Such  trophic  disturb- 
ances do  not  appear  as  complications,  but 
are  essentially  a  part  of  the  disease.  Oc- 
curring in  the  early  stages,  they  are  due 
to  involvement  of  the  peripheral  tropho- 
sensory  fibres;  late  trophic  symptoms 
may  be  dependent  upon  lesions  of  the 
ventral  horns.  Among  the  trophic  symp- 
toms are  superficial  and  perforating 
ulcerations  of  the  skin  and  other  cuta- 
neous lesions,  loss  of  the  hair  or  teeth, 
onychia;  atrophies  of  muscles,  singly  or 
in  groups;  nutritional  disease  of  the 
bones,  particularly  the  femur,  giving 
rise  to  spontaneous  fractures;  affections 
of  the  joints  known  as  arthropathies, 
with  secondary  luxations  and  displace- 
ments; oedema,  and  bed-sores. 

Case  of  man  in  whom  there  were  trans- 
verse fractures  of  both  the  upper  thigh- 
bones without  any  apparent  cause,  the 
second  fracture  occurring  after  an  inter- 
val of  four  months.  The  retarded  consoli- 
dation, with  the  enormous  callous  forma- 
tion, go  toward  proving  a  medullary 
cause  for  these  spontaneous  fractures. 
Fourmeaux  (dour,  des  Sci.  Med.  de  Lille, 
dime  10.  '93). 

Multiple  lipomata  witnessed  in  per- 
sonal ease:  These  may  be  regarded  as  a 
peculiar  trophic  manifestation  in  tabes. 
The  patient  suffered  from  lancinating 
pains  and  paresthesia  in  the  lower  ex- 
tremities. After  two  years  these  symp- 
toms disappeared  and  Instead  small  lipo- 


mata appeared  simultaneously  on  both 
forearms,  at  first  growing  larger  and  then 
remaining  stationary.  Similar  lipomata 
then  appeared  on  the  hips  and  thighs. 
The  unmistakable  symptoms  of  tabes 
only  presented  themselves  later  on. 
Tscherkassoff  (La  Med.  Mod..  Mar.  25, 
'95). 

Tabetic  patient  in  whom  a  great  many 
cerebral  nerves  were  diseased,  even  the 
seldom-affected  facial  nerve.  Asymmetry 
of  breathing  was  particularly  noticeable, 
the  left  half  of  the  thorax  being  much 
less  active  than  the  right.  Chvostek 
(Neurol.  Centralb.,  Nov.  15,  '93). 

Perforating  ulcers  almost  invariably 
develop  on  the  plantar  surfaces  of  the 
feet,  often  beneath  the  great  toe,  and 
may  be  symmetrical.  Such  ulcers  may 
occur  quite  early  in  the  disease.  I  recall 
the  case  of  a  patient  in  whom  such  ulcers 
led  to  the  discovery  that  he  was  suffering 
from  locomotor  ataxia,  the  discovery 
overwhelming  him  with  surprise. 

Herpes  is  not  an  uncommon  accom- 
paniment of  the  severe  neuralgic  or  nen- 
ritic  pains  sometimes  observed.  Bald- 
ness or  anomalies  in  pigmentation,  espe- 
cially the  former,  are  common.  The 
teeth  may  all  fall  out  as  a  result  of  in- 
volvement of  the  fifth  nerve. 

Atrophy  of  the  jaws,  with  loss  of  the 
teeth,  frequently  occurs  in  tabetic  pa- 
tients. Eosin  (Dent.  Zeit.  f.  Xervenh.. 
vol.  i,  '92). 

Case  of  tabes  with  bilateral  atrophy  in 
the  region  of  the  trigeminus,  loss  of  the 
teeth,  paralysis  of  the  soft  palate,  laryn- 
geal crises.  There  was  found  degenera- 
tion of  the  ascending  (spinal)  root  of 
the  trigeminus,  of  the  ascending  glosso- 
pharyngeus  root  (fasciculus  soli  tar  ius), 
and  of  the  substantia  feruginea.  Pacetti 
(Trans.  Eleventh  Inter.  Med.  Congress, 
'94). 

Case  of  tabes  with  perforating  ulcer  of 
the  month  and  loss  of  the  teeth.  No 
other  bulbar  symptoms  were  present. 
Letulle  (Revue  Neurol.,  Oct.  15.  '94). 

Spontaneous  loss  of  the  teeth  most  fre- 
quently occurs  in  the  later  stages  of  the 


LOCOMOTOR  ATAXIA.  SYMPTOMS. 


disease,  and  is  due  to  the  diseased  condi- 
tion of  the  nervus  trigeminus.  Lemaire 
and  Bernard  (L/Odontologie,  Feb.,  '94). 

Onychia  is  sometimes  very  trouble- 
some, and  wounds  or  operations  upon 
the  extremities,  especially  the  feet,  may 
prove  quite  obstinate  in  healing.  Mus- 
cular atrophy,  if  extensive  and  affecting 
groups  or  an  entire  limb,  is  a  late  inci- 
dent in  the  disease.  Extensive  atrophy 
occurring  early  indicates  a  probable  com- 
plication. Atrophy  of  single  muscles 
may  occur,  though  not  frequently  early, 
as  a  result  of  the  neuritis. 

From  10  to  12  per  cent,  of  all  tabetic 
patients  are  affected  with  muscular  at- 
rophy. This  tabetic  muscular  atrophy 
is  principally  characterized  by  the  great 
slowness  of  its  development;  fibrillary 
contractions  and  degeneration  reactions 
are  not  present.  Dejerine  (Ann.  de  Med. 
Thermale,  '92). 

Case  of  tabes  in  a  female  patient  in 
which  there  was  also  increasing  paralysis 
and  atrophy  of  the  lower  extremities. 
These  symptoms  were  due  to  atrophy  of 
the  peripheral  nerves  of  the  lower  ex- 
tremities, as  was  proved  by  the  post- 
mortem. Goldscheider  (Zeit.  fur  klin. 
Med.,  vol.  xix,  '92). 

Case  of  tabes  in  which  there  existed 
a  general  muscular  atrophy  and  also 
marked  involuntary  movements  of  the 
lower  extremities  and  of  the  face  during 
sleep.  Lacaze  (Montpellier  Med.,  No.  1, 
'93). 

(  ase  in  which  the  symptoms  of  pro- 
gressive muscular  atrophy  first  presented 
themselves,  those  of  tabes  only  occurring 
several  years  later.  J.  Collins  (Jour,  of 
Nerv.  and  Mental  Dis.,  Feb.,  '94). 

The  arthropathies  and  osteopathies, 
which  arc  ordinarily  associated  phenom- 
ena, have  been  especially  studied  by 
Charcot,  Dejerine,  and  others.  They 
occur  in  from  5  tp  10  per  cent,  of  cases. 
The  knees  are  chiefly  affected.  The 
smaller  joints  usually  escape,  though 
Hirtz  (La  Med.  Mod.,  9,  p.  48,  J98)  has 
recently   reported   a   case   with  radio- 


437 

graphic  illustrations,  involving  the  meta- 
tarso-phalangeal  articulations.  In  some 
cases  there  exists,  without  swelling  or 
deformity,  a  remarkable  relaxation  of  the 
muscles  of  the  knee  and  other  joints, 
permitting  extreme  degrees  of  hyper- 
flexion  and  hyperextension.  This  con- 
dition has  been  called  "hypotonia"  by 
Frenkel,  who  considers  it  an  early  symp- 
tom. 

Three  cases  of  ataxic  arthropathy  in 
one  of  which  the  disease  of  the  joint  was 
one  of  the  first  symptoms  of  tabes. 
Krogius  (Finska  Lakiire-sall.  Hand.,  vol. 
xxxv,  '93). 

Case  of  pronounced  gonitis  tabetica. 
As  the  diseased  leg  was  a  great  hindrance 
in  walking,  it  was  amputated  at  the 
thigh.    R.  Rasmus  (Inaug.  Dissert.,  '94). 

Attacks  of  oedema  in  the  extremities 
or  elsewhere,  usually  transient  and  of  a 
type  similar  to  angioneurotic  oedema, 
have  been  noted.  Bed-sores  on  the 
sacrum,  over  the  trochanters,  or  at  other 
points  exposed  to  prolonged  pressure  are 
ordinarily  late  symptoms  and  belong  to 
the  bed-ridden  stage.  In  this  connec- 
tion, an  emphatic  protest  might  be  in- 
troduced against  the  custom,  sometimes 
practiced  for  the  relief  of  pain  in  the 
legs,  of  tightly  binding  a  cord  or  liga- 
ture around  the  limb.  It  may,  and  some- 
times does,  effectually  relieve  the  pains, 
but  at  great  risk  of  inducing  far  more 
serious  trophic  disturbances. 

Vesical,  Rectal,  and  Sexual  Symptoms. 
— Slight  incontinence  or  slowness  in 
micturition  may  first  attract  attention  to 
the  possibility  of  tabes.  This  may  vary 
from  time  to  time,  and  is  rarely  extreme 
or  particularly  annoying.  In  the  late 
stage  of  the  disease  there  may  be  partial 
or  total  anaesthesia  of  the  bladder,  with 
either  absolute  incontinence  or  the  op- 
posite condition  of  retention.  The  urine 
may  be  retained  without  discomfort  for 
many  hours,  and,  unless  withdrawn  by 


438 


LOCOMOTOR  ATAXIA.    SYMPTOMS.  DIAGNOSIS. 


catheter,  a  cystitis  may  develop.  Cath- 
eterization should  be  practiced  very  care- 
fully in  such  patients. 

In  patients  suffering  from  tabes  dor- 
salis  the  bladder  can  be  voided  by  com- 
pression, only,  however,  when  the  patellar 
reflex  has  subsided.  If  in  such  cases  of 
paralysis  of  the  bladder,  occurring  in  dis- 
eases of  the  spinal  cord,  pressure  is  ex- 
erted upon  the  abdomen  in  the  region  of 
the  bladder,  it  is  often  possible  to  cause 
the  urine  to  flow  without  its  being  neces- 
sary to  use  the  catheter.  J.  Wagner 
(Wiener  klin.  Woch.,  Nov.  24,  '92). 

Tabetics  are  almost  invariably  consti- 
pated, although  in  the  advanced  disease 
incontinence  of  faeces  may  be  present. 
The  rectal  region  may  be  the  site  of 
sharp,  stabbing  pains  in  neuralgic  cases. 
Sexual  desire  and  power,  while  invari- 
ably impaired  or  abolished  in  the  ad- 
vanced disease,  is  sometimes,  in  the  be- 
ginning of  tabes,  quite  distinctly  exag- 
gerated, the  patient  being  led  into  the 
grossest  excesses  in  sexual  intercourse. 
Such  paroxysmal  satyriasis  may  give  way 
to  total  temporary  abolition  of  sexual 
function,  the  paroxysms  recurring  at 
varying  intervals. 

Special  Senses. — In  addition  to  vision, 
hearing,  taste,  and  smell  are  each  or  all 
of  them  sometimes  impaired.  Hearing 
is  affected  in  about  25  per  cent,  of  all 
cases.  Deafness  is  sometimes,  though 
rarely,  due  to  atrophy  of  the  auditory 
nerve,  sometimes  to  a  trophosclerotic 
condition  of  the  middle  ear  through  in- 
volvement of  the  fifth  nerve. 

Of  53  cases  of  tabes,  43  had  some  dis- 
order of  the  auditory  functions.  Mor- 
purgd  (L'Union  Med.,  July  3,  '90). 
•  In  20  cases  of  tabes  auditory  disturb- 
ances found  in  only  5;  of  these,  10  per 
cent,  had  nervous  deafness.  Tabes  not 
infrequently  causes  trophic  changes  in 
the  middle  ear  (a  sclerotic  process), 
which  may  lead  to  disturbances  of  hear- 
ing. Treitel  (Arch,  of  Otol.,  Oct.,  '90). 
Series  of  40  cases  of  tabes,  7  of  which 


had  normal  hearing;  29  had  some  affec- 
tion of  the  auditory  apparatus,  of  which 
4  had  middle-ear  disease,  and  15  had 
positive  internal-ear  disease,  which  was 
also  suspected  in  the  remaining  cases. 
Meniere's  symptoms  were  not  found  in 
any  case.  Marini  (Archiv  f.  Psych,  u. 
Nervenk.,  B.  21,  H.  1,  '90). 

Tabetic  lesions  of  the  auditory  nerve 
are  usually  only  present  in  the  preataxic 
stage,  notably  in  cases  of  so-called  tabes 
descendens.  Cozzolino  (Revista  Clinica  e 
Terap.,  Feb.,  '94). 

Only  four  cases  of  tabes  have  been  met 
with  up  to  the  present  in  which  atrophy 
of  the  acoustic  nerve  was  discovered  at 
autopsy.  In  the  great  majority  of  cases 
there  is  a  sclerotic  affection  of  the  middle 
ear,  which  may  be  considered  as  a  trophic 
disturbance  following  a  diseased  condi- 
tion of  the  trigeminus  nerve.  Usually 
there  is  a  more  or  less  pronounced  deaf- 
ness, which  is  generally  very  quickly  de- 
veloped, often  in  a  few  months.  In  more 
than  half  of  the  cases  a  subjective  noise 
precedes  the  deafness,  the  sound  being  of 
varied  nature  (musical,  whistling,  buzz- 
ing, etc.)  and  also  of  varying  intensity, 
sometimes  excessively  loud.  Collet  (La 
Presse  Med.,  Jan.  12,  '95). 

Taste  and  smell  are  believed  to  be 
rarely  affected,  though  Klippel  (Archiv 
de  Neur.,  3,  p.  257,  '97)  does  not  agree 
with  this  statement,  believing  that  these 
two  senses  are  much  more  frequently  in- 
volved than  is  indicated  in  the  literature. 
They  are,  moreover,  among  the  earliest 
symptoms  in  tabes,  according  to  this  au- 
thor, who  describes  the  findings  in  a 
case  of  tabes  presenting  these  symptoms, 
which  came  to  autopsy,  consisting  of 
marked  degenerative  disease  of  the  olfac- 
tory, glosso-pharyngeal,  and  trigeminus 
•  nerves  and  their  ganglia. 

Diagnosis. — The  chief  and  most  im- 
portant problem  in  diagnosis  is  with  re- 
gard to  the  prompt  recognition  of  the 
incipient  or  preataxic  stage.  Xo  single 
symptom  is  pathognomonic,  although 
the  Argyll-Robertson  pupil  is  considered 


LOCOMOTOR  ATAXIA.  DIAGNOSIS. 
I 


439 


by  Mobius  and  others  as  invariably  in- 
dicative of  either  locomotor  ataxia  or 
general  paresis.  The  conjoint  associa- 
tion of  any  two  of  the  four  most  con- 
stant symptoms — abolished  knee-jerks, 
Argyll-Robertson  pupil,  lightning  pains, 
and  ocular  palsies — is  quite  suggestive, 
if  not  diagnostic  in  importance.  The 
simultaneous  existence  of  these  four 
symptoms  occurs  in  no  other  disease,  and 
is  positively  diagnostic.  The  subsequent 
development  of  ataxia  completes  a  clin- 
ical picture  which  is  unique  and  is  not 
even  simulated  by  any  other  disease. 

It  is  always  well  to  think  of  tabes  in 
diagnosticating  abdominal  affections  ac- 
companied by  repeated  attacks  of  pain, 
even  in  the  absence  of  other  sensory  affec- 
tions, motor  or  oculo-pupillary  phenom- 
ena, or  the  preservation  of  the  knee-jerks. 
Laget  (La  Semaine  Med.,  Sept.  23,  '91). 

The  patellar  reflex  is  never  absent  in 
healthy  persons,  but  only  when  there  is 
structural  disease  of  the  musculo-nervous 
system.   Gowers  (Clin.  Jour.,  Oct.  4,  '93). 

The  symptom  described  by  Pitres  as 
haphalgesia  (sensation  of  pain  upon  deli- 
cate touching  with  certain  substances)  is 
not  a  pathognomonic  symptom  of  hys- 
teria, but  may  also  occur  in  tabetic  pa- 
tients. Lannois  (La  Sem.  Med.,  Aug.  31, 
'92). 

Symptoms  of  tabes  dorsalis  may  be 
partially  simulated  by  a  peripheral  neu- 
ritis, even  without  a  diseased  condition 
of  the  spinal  cord.  In  cases  in  which 
peripheral  neuritis  is  rapidly  developed 
the  following  symptoms  furnish  the  dif- 
ferential diagnosis  of  pseudotabes  ;  very 
rapid  progress  of  the  disease ;  pain  in  the 
muscles  proper  and  in  the  nerve-trunks; 
undisturbed  pupillary  reaction.  Dejerine 
(La  Sem.  Med.,  No.  2G,  '93). 

Marked  hyperflexion  of  the  leg  at  the 
hip-joint,  without  bending  it  at  the  knee, 
is  painful  in  healthy  subjects,  while  in 
tabetics,  even  during  the  first  stages  of 
the  disease,  it  causes  no  pain.  Putnam 
(Boston  Med.  and  Surg.  Jour.,  Aug.,  '95). 

The  paresthesia  in  the  region  of  the 
trigeminus  designated  as  "Hutchinson's 
mask,"  with  a  feeling  as  of  a  spider-web 


over  the  skin  of  the  face,  may  be  met 
with  in  the  early  stages  of  tabes,  and  is  of 
diagnostic  value.  Mobius  (Neurol.  Beit., 
No.  3,  '95). 

Twenty  tabetics  in  which  it  was  found 
that  on  presure  upon  the  ulnaris,  in  the 
sulcus  ulnaris  at  the  elbow,  there  was  no 
sensation  of  pain  fourteen  times  on  both 
sides  and  once  on  one  side.  Considered  a 
pathognomonic  symptom  of  tabes.  Bier- 
nacki  (Gaz.  Lekar.,  No.  2,  '94). 

Literature  of  '96-'97-'98. 

In  many  early  cases  of  tabes  there  is 
insensibility  to  pain  on  pressure  and  on 
tapping  of  the  popliteal  nerve,  this  symp- 
tom is  more  commonly  present  than 
Biernacki's  sign  of  anaesthesia  of  the 
ulnar  nerve.  Bechterew  (Neurol.  Cen- 
tralb.,  p.  140,  '98). 

There  is  no  pathognomonic  symptom 
of  tabes,  but  two  symptoms  are  con- 
sidered of  value  in  making  an  early  di- 
agnosis. The  first  is  the  remarkable  in- 
crease of  the  abdominal-wall  reflex. 
Abdominal  or  other  cutaneous  and  ten- 
don-reflexes are  antagonistic  phenom- 
ena, and  this  antagonism  may  serve,  in 
doubtful  cases,  as  a  means  of  diagnosis. 
Patients  during  the  first  period  of  loco- 
motor ataxia  with  loss  of  the  patellar 
reflex  have  an  unusually-marked  ab- 
dominal reflex,  while  the  lack  of  the 
latter,  along  with  increased  patellar  re- 
flex, is  indicative  of  a  cerebral  lesion, 
which  causes  no  irritation  in  the  neigh- 
borhood of  the  affected  spot.  The  second 
sign  is  the  behavior  of  the  patient  when 
asked  to  rise  on  his  toes,  with  his  eyes 
closed,  and  to  remain  standing.  Those 
in  the  first  period  of  tabes,  with  only 
the  slightest  symptoms  of  musculo-tonic 
troubles,  and  without  any  sensible  alter- 
ation, are  not  able  to  execute  this  act. 
O.  Rosenbach  (Brit.  Med.  Jour.,  Oct.  1. 
'98). 

Among  the  diseases  to  be  considered 
and  which  at  times  obscure  the  diagnosis, 
are  ataxic  paraplegia,  disseminated  scle- 
rosis, brain-tumors,  certain  forms  of  mye- 
litis; the  syphilitic  meningomyelitis  of 
Oppenheim,  Sachs,  and  others;  multiple 
neuritis,  and  post-diphtheritic  paralysis. 


440 


LOCOMOTOR  ATAXIA.  DIAGNOSIS. 


In  the  ataxic  paraplegia  of  Gowers 
there  is  actual  loss  of  motor  function 
with  spasticity,  the  knee-jerks  being  usu- 
ally exaggerated  with  little  if  any  pain, 
no  crises,  no  arthropathies,  and  no  in- 
volvement of  the  muscles  of  the  eye. 

Two  cases  of  ataxic  paraplegia.  In 
both  cases  the  ataxia  was  very  marked, 
but  yet  seemed  to  differ  materially  from 
tabetic  ataxia.  Cocking  (Brit.  Med. 
Jour.,  Jan.  14,  '93). 

In  multiple  sclerosis  there  may  be 
ocular  palsies,  pains  (slight)  in  the  lower 
extremities,  defects  of  sensation,  sphinc- 
teric  involvement,  ataxia,  and  even 
abolished  knee-jerks.  The  knee-jerks 
are  usually  exaggerated,  however;  the 
pains  differ  in  degree  and  character,  and 
in  disseminated  sclerosis  the  peculiar 
speech,  intention-tremor,  nystagmus,  and 
special  variety  of  optic  atrophy  (Gnauck) 
are  distinctive. 

Literature  of  '96-'97-'98. 

Locomotor  ataxia  resembles  dissemi- 
nated sclerosis  (1)  in  often  showing  in 
its  early  stages  sparse,  scattered,  sclerotic 
lesions;  (2)  in  possessing  other  anatom- 
ico-clinical  syndromes,  which  correspond 
to  other  scattered  centres  of  sclerosis  of 
the  nervous  system;  (3)  in  being  fre- 
quently associated  in  the  same  subject 
with  various  scleroses  of  other  organs  be- 
sides the  nervous  system.  The  etiology 
of  both  diseases  is  very  complex.  Syphi- 
lis is  the  most  frequent  cause,  but  it  is 
not  the  only  etiological  factor,  even  in 
cases  in  which  it  is  found.  Arthritis, 
different  intoxications,  the  neuropathic 
disposition,  and  several  other  causes  may 
all  co-operate  to  produce  the  disease  and 
determine  its  localization  in  the  cord. 
Grasset  (Gaz.  Med.  de  Liege,  Aug.  26, 
'97) 

Ataxia  is  common  in  tumor  of  the 
cerebellum,  the  frontal  lobes,  and  the 
base  of  the  brain.  Optic  atrophy  and 
ocular  palsies  are  also  frequently  encoun- 
tered.  Attacks  of  cerebral  vomiting  may 


simulate  the  gastric  crises  of  tabes.  The 
clinical  picture  and  history  of  focal  pal- 
sies, headache,  hebetude,  etc.,  in  brain- 
tumors  serve  to  distinguish  the  two  con- 
ditions quite  readily.  In  myelitis  the 
absence  of  optic  atrophy,  ocular  palsies, 
and  Argyll-Robertson  pupil  are  sufficient 
to  eliminate  any  element  of  temporary 
confusion.  In  multiple  neuritis  the  deep 
reflexes  are  abolished  or  diminished, 
there  may  be  much  pain,  and  the  ataxia 
may  be  decided.  The  rapid  atrophy  and 
true  motor  weakness,  with  altered  elec- 
trical reactions,  together  with  absence  of 
pupillary  changes,  and  preserved  light- 
reflex  establish  the  diagnosis  readily. 
Post-diphtheritic  paralysis,  when  it  sim- 
ulates, through  the  ataxia  and  sensory 
symptoms  present,  true  tabes  dorsalis,  is 
a  multiple  neuritis,  and  the  differential 
data  are  the  same.  In  syphilitic  men- 
ingomyelitis  there  is,  at  times,  a  close 
clinical  resemblance  to  true  locomotor 
ataxia.  In  such  cases,  however,  motor 
as  well  as  sensory  defect  is  present,  the 
symptoms  are  unilateral  or  at  least  un- 
equal in  degree  on  the  two  sides,  the 
Argyll-Kobertson  pupil  is  not  present, 
and  prompt  improvement  nearly  always 
follows  the  energetic  use  of  potassium 
iodide  and  mercury. 

Should  the  disease  begin  in  the  cer- 
vical cord,  it  is  at  times  difficult  to  dif- 
ferentiate locomotor  ataxia  from  syringo- 
myelia: a  fact  which  has  been  especially 
emphasized  by  Marie.  Cervical  tabes  is 
a  rare  form  of  the  disease,  Dejerine  find- 
ing only  one  such  primarily  in  one  hun- 
dred and  one  cases  at  the  Bicetre. 

Case  of  a  tabetic  patient  having  sym- 
metrical gangrene  of  the  toes,  and  who 
also  showed  the  well-known  dissociation 
of  sensibility:  therefore  syringomyelia 
might  also  have  been  suspected:  there 
was.  however,  no  muscular  atrophy. 
Post-mortem  showed,  besides  the  sclerosis 
of  the  posterior  columns,  an  acute  neu- 


LOCOMOTOR  ATAXIA.  ETIOLOGY. 


441 


ritis  of  both  nervi  peronei.  Kornfeld 
(Wiener  med.  Woch.,  Nov.  5,  '92). 

Literature  of  '96-'97-'98. 

[Psychical  disturbances  during  the 
course  of  tabes  are  rather  rare,  but  not 
quite  so  rare  as  is  usually  believed.  It 
is  necessary,  in  such  cases,  to  carefully 
guard  against  confounding  these  disturb- 
ances with  a  condition  of  dementia  para- 
lytica combined  with  ataxic  symptoms. 
H.  Obersteiner,  Assoc.  Ed.,  Annual, 
'96.] 

All  cases  of  gradually-progressive 
blindness — if  dependent  upon  optic  at- 
rophy and  especially  if  occurring  in  ne- 
groes— should  excite  suspicion  and  lead 
to  careful  examination  for  the  presence 
of  other  symptoms  of  locomotor  ataxia. 

Etiology. — Heredity  is  of  very  minor 
importance,  if,  indeed,  it  is  a  factor  at 
all  in  the  etiology  of  the  disease. 

Literature  of  '96-'97-'98. 

Mother  and  son,  aged  51  and  27  years, 
respectively,  both  suffering  from  typical 
locomotor  ataxia.  There  was  nothing 
whatever  to  suggest  syphilis  either  in 
the  history  or  in  the  patients.  In  the 
mother  the  disease  began  at  31  years; 
in  the  son  at  26  years  of  age.  Other 
cases  have  been  recorded  in  which  the 
children  of  parents  wno  had  locomotor 
ataxia  showed  symptoms  of  the  disease 
much  earlier  than  in  this  case,  but  in 
children  the  diagnosis  must  be  made  with 
caution,  as  Friedreich's  disease  is  easily 
mistaken  for  locomotor  ataxia.  Kalischer 
(Neurol.  Centralb.,  Dec,  '97). 

The  same  is  true  of  diathetic  states, 
although  a  rheumatic  predisposition  may 
possibly  favor  its  development.  Next  to 
syphilis,  the  occupation  and  previous 
habit  of  the  individual  as  regards  ex- 
cesses, particularly  physical,  are  most  im- 
portant. Kailroad-employees,  especially 
engineers,  soldiers,  sailors,  policemen, 
lumbermen,  drivers,  and  others  whose 
work  combines  exposure  to  wet  and  cold, 


with  severe  physical  exertion,  are  quite 
numerous  among  the  victims  of  tabes. 
Excesses  in  athletic  sports,  in  dancing, 
and  in  sexual  intercourse  are  all  consid- 
ered adequate  predisposing  or  even  ex- 
citing causes  when  combined  with  syph- 
ilis. 

Two  cases  of  tabes  in  females  who  had 
worked  excessively  at  sewing-machines. 
Guelliot  (L'Union  Med.,  Nos.  2  to  4,  '82). 

Case  of  tabes  in  a  woman,  aged  28, 
without  a  history  of  syphilis  or  heredi- 
tary defects,  who  worked  a  double-pedal 
sewing-machine  from  morning  until  mid- 
night for  several  years  before  her  symp- 
toms appeared.  Bernhardt  (Neurol.  Cen- 
tralb., Dec,  '90). 

Traumatism  to  the  spine  in  the  nature 
of  direct  violence  or  concussion,  as  from 
a  violent  fall  on  the  feet,  has  been,  in 
some  instances,  the  only  apparent  cause. 

Tabes  traumatica  is  of  very  rare  occur- 
rence and  has  no  characteristic  symp- 
toms. Should,  however,  a  trauma,  either 
alone  or  in  combination  with  exposure  to 
cold,  be,  under  certain  circumstances,  the 
promoting  cause  of  tabes,  we  should  be 
forced  to  assume  that,  in  these  cases,  the 
trauma  or  the  cold  had  proved  the  agent 
inducing  the  formation  of  a  poison  cor- 
responding, in  its  operation  upon  the 
nervous  system,  with  the  hypothetic 
poison  of  syphilitic  infection.  Hitzig 
(Fest.  zur  200  Jahrigen  Jubelfeier,  in 
Halle,  '94). 

The  current  view  that  locomotor  ataxia 
may  be  caused  by  traumatism  per  se, 
irrespective  of  a  direct  lesion  of  the  cord, 
is  not  sustained  by  the  published  evidence 
thus  far  adduced.  It  would  seem,  aside 
from  mere  coincidence,  that,  when  a 
sclerosis  of  the  posterior  columns  develops 
after  a  traumatism,  the  subject  was  al- 
ready doomed  to  this  condition,  the  proc- 
ess having  already  begun,  and  that  the 
traumatism  at  most  only  accelerated  the 
development  of  the  symptoms  and  pos- 
sibly of  the  anatomical  process.  Mori  on 
Prince  (Jour,  of  Nerv.  and  Mental  Dis., 
Feb.,  '95). 


LOCOMOTOR  ATAXIA.  ETIOLOGY. 


Literature  of  '96-'97-'98. 

Case  in  which,  five  weeks  after  trau- 
matic rupture  of  the  thigh-muscles,  pains 
came  on  in  the  legs ;  in  seven  months  the 
gait  was  uncertain,  and  in  a  year  the 
man  was  suffering  from  typical  tabes. 
The  patient  had  not  suffered  from  any 
symptoms  of  tabes  before  the  accident. 
Syphilis  as  well  as  other  possible  causes 
of  tabes  were  excluded.  In  this  case  an 
ascending  neuritis  was  probably  followed 
by  the  tabes.  Lammers  (Centralb.  f. 
inner.  Med.,  July  31,  '97). 

Of  all  the  etiological  factors,  syphilis 
appears  most  constantly  and  is  unques- 
tionably of  the  greatest  importance. 
Many  neurologists,  indeed, — among  them 
Mobius,  Tarnowski,  and  others, — believe 
that  the  development  of  locomotor  ataxia 
implies  necessarily  the  pre-existence  of 
syphilis.  This  is,  beyond  question,  an 
exaggerated  estimate  of  the  facts,  but  it 
is  also  true  that  a  history  or  collateral 
evidence  of  syphilis  can  be  elicited  or 
demonstrated  in  more  than  50  per  cent, 
of  all  cases.  Erb  found  89  per  cent,  in 
300  private  cases.  The  exact  pathogen- 
etic relationship  is  not  clear.  Syphilis 
is  more  than  an  indirect  or  simple  pre- 
disposing factor,  and  yet  the  length  of 
time  usually  elapsing  between  the  period 
of  syphilitic  infection  and  the  symptom- 
atic beginning  of  locomotor  ataxia  would 
indicate  that  its  action  must  be  quite  in- 
direct. The  interval  sometimes  amounts 
to  thirty  years  or  more.  On  the  other 
hand,  I  have  seen  well-marked  locomotor 
ataxia  present  in  a  patient  who  was  at 
the  time  under  energetic  treatment  for 
cutaneous  syphilis,  infection  by  senile 
chancre  having  occurred  less  than  18 
months  previously.  Three  years  later 
the  disease  was  still  present,  though 
not  advancing.  In  34  cases  personally 
observed  by  me  the  average  interval 
between  the  period  of  syphilitic  in- 
fection and  the  first-recognized  symp- 


I  toms  of  locomotor  ataxia  was  9  1/2 
|  years. 

Case  of  patient  who,  in  1878,  developed 
pronounced  signs  of  tabes;  in  1883  he 
contracted  syphilis,  from  which  time  the 
tabetic  symptoms  rapidly  developed.  The 
case  proves  that  syphilis  is  not  neces- 
sarily the  cause  of  tabes.  Leloir  (Jour, 
de  Med.  de  Paris,  Dec.  1,  '89). 

Syphilis  may  provoke  nutritive  dis- 
turbances of  the  system,  which  render  a 
person  more  liable  to  tabes  than  one  who 
has  not  had  specific  disease;  but  tabes 
is  not  a  symptom  of  syphilis,  being  an 
independent  disease,  upon  which  syphilis 
has  only  an  indirect  eff  ect.  Vermel  (Le 
Prog.  Med.,  Feb.  22,  '90). 

Tabes  is  a  "disease  of  exhaustion"  of 
the  spinal  cord,  referable  to  a  disturbance 
of  the  nutrition  of  the  cord,  induced  by 
some  noxious  agent  (notably  syphilis). 
Edinger  (Volkmann's  Samml.  klin.  Vort., 
No.  106,  '94). 

Syphilis  is  the  only  important  etiolog- 
ical factor  in  tabes,  being  the  true  and 
almost  the  sole  cause,  all  other  influ- 
ences being  of  comparatively  little  im- 
portance. Besides  syphilis  the  nervous 
condition  of  Mretlite  nerveuse  may  alone 
be  considered  as  an  important  primary 
cause.  Marie  (Legons  sur  les  Mai.  de  la 
Moelle,  '92). 

Case  of  early  tabes  syphilitica  in  which 
the  first  symptoms  of  tabes  showed  them- 
selves four  months  after  the  chancre,  in 
the  form  of  laryngeal  crises,  and  in  the 
space  of  five  and  a  half  months  tabes  was 
fully  developed;  the  course  of  the  dis- 
ease, notwithstanding  continuous  anti- 
syphilitic  treatment,  was  very  rapid. 
Pauly  (Lyon  Med.,  June  12,  '92). 

The  relationship  of  syphilis  to  tabes  is 
demonstrated  by  the  frequent  occurrence 
of  paresis  with  tabes,  and  of  tabes  in  the 
course  of  general  paresis.  The  occurrence 
of  symptoms  in  the  course  of  tabes  which 
arc  often  due  to  syphilis.- — ocular  palsies, 
loss  of  pupillary  reflexes,  and  even  light- 
ning pains.  The  effect  of  mercurial  ami 
iodide  treatment  upon  many  of  the  symp- 
toms of  tabes.  Sachs  (X.  Y.  Med.  Jour., 
Aug.  12,  '93). 

[The  first  symptoms  of  tabes  only 
occur  several  years  after  syphilitic  infec- 
tion, most  frequently  from  the  sixth  to 


LOCOMOTOR  ATAXIA.  ETIOLOGY. 


443 


Of  more  than  400  cases  of  tabes,  in 
about  90  per  cent,  there  was  a  previous 
history  of  syphilis.  Gajkiewiecz  ("Syph. 
du  Sys.  Nerv.,"  '92). 

From  a  study  of  the  reports  of  the  neu- 
rological section  of  the  Charite  Hospital, 
Berlin,  it  is  found  that  syphilis  positively 
existed  previously  in  37  per  cent,  of  the 
cases,  most  probably  in  31  per  cent.,  and 
possibly  in  7  per  cent.  Kuhn  (Inaug. 
Dissert.,  '94). 

In  30  cases  not  one  found  without  a  his- 
tory of  antecedent  syphilis.  Schwarz 
(St.  Petersburger  med.  Woch.,  p.  259, 
'89). 

There  was  personally  found  under  the 
guidance  of  Leyden,  who  still  denies  the 
etiological  significance  of  syphilis  for 
tabes,  among  108  cases,  only  20.4  per  cent, 
which  were  undoubtedly  syphilitic  and 
58.3  per  cent,  non-syphilitic.  Storbeck 
(Lyon  Med.,  '95). 

Although  syphilis  could  be  proved  in 
about  55  per  cent,  of  225  cases,  in  many 
of  them  it  was  associated  with  other 
causes  of  tabes  dorsalis, — as  hereditary 
joint-affections,  alcoholism,  sexual  excess, 
etc.;  so  that  the  exact  percentage  which 
could  safely  be  attributed  to  syphilis  was 
reduced  to  22.33  per  cent.  Pitres  (Lan- 
cet, Apr.  13,  '95). 

In  non-tabetic  patients  above  the  age 
of  eighteen  a  history  of  syphilis  was 
found  in  only  22.5  per  cent.,  whereas  in 
tabetics  it  reached  72.8  per  cent.  There 
is  a  close  connection  between  syphilis  and 
tabes;  tabes  is  a  consecutive  affection  to 
syphilis,  somewhat  similar  to  the  pa- 
ralysis which  may  follow  diphtheria. 
Sarbo  (Pester.  Med.-chir.  Presse,  xxxiv, 
3  to  5). 


the  tenth  year;  only  very  rarely  does 
tabes  show  itself  in  the  florid  stage  of 
syphilis.  H.  Obersteiner,  Assoc.  Ed., 
Annual,  '93.] 

An  hereditary  nervous  taint  is  very 
frequently  present  in  tabetic  disease 
(fifty-one  times  in  eighty-one  cases),  and 
the  action  of  the  syphilis  upon  the  nerv- 
ous system  is  thereby  promoted.  Rosen- 
blatt (Dissertation,  '93). 

In  all  of  thirty-nine  cases  a  previous 
syphilitic  infection  was  probable;  if 
tabes  exist  without  syphilis,  the  tabetic 
virgin  must  certainly  be  one  day  brought 
to  light.  Mobius  (Centralb.  f.  Nervenh., 
Psych.,  u.  gerich.  Psychop.,  Sept.,  '93). 

In  Japan  syphilis  is  very  wide-spread, 
while  tabes  but  seldom  comes  under  ob- 
servation. Grimm  (Inter,  klin.  Pund., 
Aug.  29,  '94). 

Of  500  cases  of  tabes  10.8  per  cent,  were 
not  infected  and  89.2  per  cent,  were  in- 
fected with  syphilis.  Of  50  additional 
cases,  from  the  lower  classes,  12,  or  24 
per  cent.,  did  not  show  evidence  of  infec- 
tion, while  38,  or  76  per  cent.,  did. 

Concerning  other  possible  etiological 
causes,  or  combination  of  causes,  the 
cases  are  grouped  as  follows:  Syphilis 
alone,  27  per  cent.;  syphilis  and  cold,  11 
per  cent.;  syphilis  and  fatigue,  6  per 
cent.;  syphilis  and  sexual  excesses,  9.6 
per  cent.;  syphilis  and  trauma,  1.7  per 
cent.;  syphilis  and  neuropathic  tenden- 
cies, 12  per  cent.;  syphilis,  cold,  and 
fatigue,  13.5  per  cent. ;  syphilis,  cold,  and 
excesses,  1.7  per  cent.;  syphilis,  fatigue, 
and  excesses,  0.7  per  cent.;  syphilis, 
trauma,  cold,  or  excesses,  1  per  cent.; 
neuropathic  tendencies  alone,  0.7  per 
cent.;  cold  alone,  1.4  per  cent.;  fatigue, 
0.3  per  cent. ;  sexual  excesses,  1  per  cent. ; 
cold  and  fatigue,  0.7  per  cent.;  trauma, 

0.  3  per  cent.;  several  causes,  but  not 
syphilitic,  1.4  per  cent.;  cases  without 
demonstrable  cause,  but  in  several  of 
which  syphilis  was  suspected,  5.4  per 
cent.    Erb  (Practitioner,  Sept.,  '91). 

Of  the  tabetic  men  examined,  56.25  per 
cent,  had  certainly  had  syphilis;  and  of 
the  women,  66.7  per  cent.  In  21.90  per 
cent,  of  the  men  and  33.3  per  cent,  of  the 
women  there  was,  in  all  probability, 
syphilis.    Gerlach  (Port,  der  Med.,  Feb. 

1,  '91). 


Literature  of  '96-'97-'98. 

A  cause  which  enters  as  a  possible  fac- 
tor in  producing  locomotor  ataxia  is  the 
long-continued  and  uninterrupted  admin- 
istration of  large  or  even  measureably 
large  doses  of  iodide  of  potash,  which  is 
so  commonly  given  at  the  present  day  in 
the  treatment  of  syphilis.  C.  T.  Drennon 
(Alienist  and  Neurol.,  Oct.,  '96). 

Although  syphilis  is  exceedingly  com- 
mon among  negroes,  after  more  than  a 
decade's  practice  no  case  of  locomotor 


LOCOMOTOR  ATAXIA.  ETIOLOGY. 


ataxia  seen.    C.  S.  Briggs  (Atlanta  Med. 
and  Surg.  Jour.,  Nov.,  "97). 

The  exact  mode  of  origin  of  tabes  is 
still  obscure,  but  the  writer  rather  in- 
clines in  the  view  that  it  should  be 
classed  as  a  tertiary  manifestation  of 
syphilis,  though  exposure  to  cold,  trauma- 
tism, or  poisons  may  call  forth  or  help 
to  bring  about  the  appearance  of  the  dis- 
ease even  in  the  absence  of  syphilis. 
Obersteiner  (Berl.  klin.  Woch.,  Oct.  18, 
•97). 

The  idea  is  rapidly  gaining  ground  that 
locomotor  ataxia  is  in  no  case,  perhaps, 
directly  due  to  syphilis,  but  to  the  action 
of  some  other  poison  or  poisons,  the  de- 
velopment or  activity  of  which  is  favored 
not  only  by  the  presence  of  syphilitic 
poison,  but  by  other  conditions  whereby 
a  morbid  state  of  the  body  is  induced  and 
the  resistance  of  the  tissues  diminished. 
Editorial  (Modern  Med.  and  Bact.  Re- 
view, Apr.,  '97). 

The  previous  history  of  47  cases  of 
tabes  carefully  examined,  and  in  only  8 
cases  could  the  writer  find  no  history  of 
syphilis,  and  in  3  of  these  preceding 
syphilis  was  probable.  In  32  cases  there 
was  a  very  definite  history  of  syphilis, 
and,  of  these,  10  were  only  treated  for 
syphilis  for  a  short  time  early  in  the  dis- 
ease. In  21  cases  there  had  been  a  second 
course  of  treatment,  and  in  only  1  case 
had  there  been  repeated  intermittent 
treatment,  and  then  for  only  one  and  a 
half  years.  In  some  cases  of  tabes,  when 
actually  established,  an  antisyphilitic 
treatment  may  be  of  service.  Homen  j 
(Neurol.  Centralb.,  p.  1026,  '97). 

Examination  of  257  cases  of  tabes,  tend- 
ing to  prove  that  syphilis  is  a  cause :  ( 1 ) 
on  the  statement  of  the  patient,  based  on 
a  doctor's  opinion:  (2)  on  the  former 
presence  of  an  ulcer  with  secondary 
symptoms;  (3)  on  the  presence  of  an 
ulcer  of  undetermined  character,  but  fol- 
lowed  by  secondary  symptoms.  Cases 
with  a  history  of  soft  chancre  are  put 
into  a  separate  group.  Of  the  257  cases 
(including  three  women),  there  was  cer-  | 
tain  syphilis  in  38.9  per  cent.,  probable 
history  in  19.8,  and  a  history  of  soft 
chancre  in  5.8.  In  34.2  per  cent,  syphilis 
was  the  only  apparent  cause.  Generally 
tabes  commenced  between  the  fifth  and 


tenth  years  after  infection,  and  fairly 
often  between  the  tenth  and  twentieth 
years.  Tumpowski  (Deut.  Zeit.  f.  Ner- 
venh.,  x,  '97). 

Series  of  observations  based  upon  12 
cases  of  tabes.  Syphilis  was  the  cause  in 
the  majority  of  cases,  but  attention  is. 
called  to  the  potency  of  cold  in  bringing 
out  the  symptoms  of  a  latent  tabes.  Op- 
tic atrophy  was  present  in  2  out  of  the  12 
cases.  Ataxia  and  pains  were  often  ab- 
sent in  these  cases.  Bladder-symptoms 
were  often  among  the  earliest  manifesta- 
tions; they  appeared  as  irritability  of  the 
organ  or  as  weakness  of  the  sphincter  or 
detrusor.  Two  exhibited  tabetic  arthrop- 
athy, which  assumed  the  hypertrophic 
or  benign  form  of  Marie;  in  1  case  there 
was  a  spontaneous  fracture.  Aortic  dis- 
ease was  present  in  2  cases.  Trevelyan 
(Quart.  Med.  Jour.,  July,  '98). 

In  a  series  of  61  cases  a  history  of 
syphilis  was  given  in  31  of  49  cases  ex- 
amined. In  the  other  18  there  Avas  evi- 
dence of  possible  exposure  to  the  disease. 
In  the  remaining  12  syphilis  was  either 
denied  or  the  point  was  not  determined. 
In  most  of  the  cases  the  initial  symp- 
toms of  ataxia  appeared  in  from  eight 
to  fifteen  years  after  syphilis  had  devel- 
oped. In  2  cases  the  disease  followed 
soon  after  mechanical  injury.  A  history 
of  exposure  to  wet  and  cold  was  given  in 
7  cases;  1  case  developed  immediately 
after  typhoid  fever.  Ln  29  cases  the  dis- 
ease first  appeared  between  the  ages  of 
thirty  and  forty.  In  2  cases  it  began  at 
the  age  of  25,  and  in  the  1  following 
typhoid  fever  at  22  years.  In  37  eases 
the  initial  symptom  was  pain  in  some 
part  of  the  body,  usually  described  as 
rheumatic.  In  3  cases  it  was  gastric 
crises;  in  3  cases  laryngeal  crises:  in 
4,  inco-ordination  of  the  lower  limbs. 
W.  H.  Riley  (Jour.  Nerv.  and  Mental 
Dis.,  Sept.,  '98). 

Following  facts  mentioned  as  antago- 
nistic to  the  syphilis  theory  of  tabes: 
1.  The  rarity  of  tabes  dorsalis  among  the 
Kirghiz  of  Central  Asia,  despite  the  fact 
that  syphilis  is  very  common.  2.  Syphilis 
is  common  among  negroes,  but  tabes  is 
almost  unknown.  3.  In  Bosnia  and  Her- 
zegovina syphilis  is  extremely  common, 
but  tabes  rare.   This  is  true  alsp  of  Abys- 


LOCOMOTOR  ATAXIA.  PATHOLOGY. 


445 


sinia.  Among  the  Arabs,  despite  the  fre- 
quency of  lues,  general  paralysis  is  rare. 
Tabes  is  also  rare  among  prostitutes,  al- 
though most  of  them  are  syphilitic.  S.  H. 
Scheiber  (Deut.  med.  Woch.,  Sept.  22, 
'98). 

The  factors  of  age  and  sex  are  of  in- 
terest. •  The  disease  is  one  rather  peculiar 
to  the  period  of  virile  manhood,  the 
years  between  25  and  45  showing,  by  far, 
the  largest  number  of  cases.  True  loco- 
motor ataxia  rarely,  if  ever,  occurs  in 
childhood. 

Ten  cases  of  true  tabes  in  childhood. 
In  six  cases  the  disease  began  before  the 
tenth  year,  and  in  four  between  the  tenth 
and  fourteenth  years.  In  the  majority  of 
cases  hereditary  syphilis  was  not  indi- 
cated. Hildebrandt  (Ueber  Tabes  Dor- 
salis  in  Kindersalter,  '92). 

Males  are  more  liable  to  the  disease 
than  females  in  the  ratio  approximately 
of  10  to  1.  Climate  and  race  are  unim- 
portant factors,  though,  in  my  personal 
observations,  out  of  34  cases,  14  were 
Irish  or  Irish- Americans.  The  negro 
has  been  considered  heretofore  as  rather 
peculiarly  exempt  from  posterior  spinal. 
This  exemption,  it  seems,  is  apparent 
rather  than  real,  at  least  in  large  degree, 
the  disease  probably  occurring  much 
oftener  in  the  negro  than  hitherto  sup- 
posed, but  escaping  recognition  because 
of  the  anomalous  clinical  form — amau- 
rotic tabes — in  which  it  appears  in  this 
race.  McConnell  has  recently  published 
the  records  of  five  cases  of  tabes  in  pure- 
blooded  negroes — the  only  cases  observed 
in  negroes  in  eight  years'  service  at  the 
Philadelphia  Polyclinic,  all  of  whom  ex- 
hibited the  amaurotic  type. 

Statistics  of  1G42  cases  of  nervous  dis- 
ease of  all  kinds,  there  being  496  male 
and  2G4  female  Russians;  also  449  male 
and  4.33  female  Jews.  Among  the  male 
Russians  25  per  cent,  were  syphilitic,  and 
among  the  females  11.4  per  cent.;  among 
the  Jews  only  7  per  cent.,  and  among  the 
Jewesses  only  1.5  per  cent.    Among  the 


Russians  of  both  sexes  the  proportion  of 
tabes  was  five  times  greater  than  among 
the  Jews.  Minor  (Neurol.  Centralb., 
July  1,  '92). 

Pathology. — Ordinarily  the  gross  ma- 
croscopical  appearances  observed  post- 
mortem in  this  disease  are  both  conspicu- 
ous and  constant.  The  cord  is  flattened 
antero-posteriorly  from  shrinkage  in  the 
posterior  columns,  which  are  also  un- 
naturally gray  in  color.  Microscopically 
the  nerve-tissue  proper  is  found  to  be 
sparse  or  to  have  almost  completely  dis- 
appeared in  certain  localities,  its  place 
having  been  taken  by  an  overgrowth  of 
connective  tissue.  The  area  most  affected 
is  that  of  the  lumbar  enlargement  and 
lower  dorsal  region,  and  the  fibres  which 
exhibit  the  greatest  damage  and  destruc- 
tion are  those  of  the  columns  of  Gall  and 
Burdach  and  the  Spitzka-Lissauer  tract. 
Higher  up,  and  as  the  disease  advances, 
similar  changes  are  noted  in  Clarke's 
vesicular  tract.  G-owers's  sensory  tract  in 
the  antero-lateral  field  is  quite  often  in- 
volved and  sometimes  quite  early.  Less 
constantly  the  direct  cerebellar  tract 
shows  similar  degenerative  changes;  but 
implication  of  the  crossed  pyramidal 
fibres  or  Turck's  columns  occurs  only  as 
a  complication. 

Case  of  a  man,  aged  31,  who  died  two 
years  after  his  first  symptoms  of  tabes, 
which  consisted  of  crises  of  pain  chiefly 
localized  in  the  right  side  of  the  thorax, 
slight  inco-ordination,  abnormal  pupil- 
lary reactions,  abolition  of  the  knee-jerks. 
The  post-mortem  examination  revealed  a 
normal  condition  of  the  peripheral  nerves 
and  the  meninges,  but  in  the  cord  a 
sclerosis,  beginning  in  the  dorsal  region 
and  increasing  in  intensity  upward  to 
cervical,  limited  to  the  median  portion 
of  the  column  of  Burdach.  This  sclerosis 
was  purely  neuroglial-,  and  independent 
of  vascular  changes.  Raymond  (La  Sem. 
Med.,  Mar.  14,  '91). 

The  posterior  roots  and  ganglia  are 


446 


LOCOMOTOR  ATAXIA.  PATHOLOGY. 


also  involved,  sometimes  quite  exten- 
sively. If  the  disease  lias  been  of  long 
duration  and  has  reached  the  paralytic 
stage,  the  anterior  gray  horns  are  apt  to 
show  degenerative  changes  in  both  fibres 
and  cells. 

Destruction  more  or  less  complete  of 
the  nerve-elements  in  the  posterior  horns 
is  quite  often  apparent  microscopically. 
Autopsies  have  been  reported  from  time 
to  time  in  which  extensive  degenerative 
disease  of  the  peripheral  nerve-fibres  or 
neuraxons  has  been  noted,  but  such  pe- 
ripheral changes  have  been  considered, 
until  recently,  as  of  secondary  rather 
than  primary  importance.  Pathogenet- 
ically  the  disease  has  been  considered  as 
primarily  of  vascular  origin,  an  exuda- 
tion of  lymph  leading  to  a  proliferation 
or  neoplastic  infiltration  of  the  neuroglia 
or  connective  tissue,  with  consequent 
compression  and,  ultimately,  structural 
disintegration  of  the  nerve-fibres.  This 
represents  a  resume  of  the  older  and 
hitherto-accepted  teachings  as  to  the  pa- 
thology and  morbid  anatomy. 

Recent  methods  of  pathological  re- 
search with  the  correlated  studies  in  this 
field  of  Cajal,  Van  Gehuchten,  Marie, 
Kedlich,  Hodge,  and  others  have,  how- 
ever, brought  to  light  facts  which  de- 
mand modifications  of  these  views  so 
radical  as  to  be  almost  revolutionary. 
The  exact  pathogenesis  of  tabes  is  as  yet 
an  incomplete  chapter  in  the  history  of 
this  disease,  but  enough  has  been  proved 
to  demonstrate  that  it  is  not  a  primary 
sclerosis  of  the  posterior  columns.  The 
recognition  and  acceptance  of  the  theory 
of  the  neurons  was  an  important  step  in 
establishing  this  fact.  According  to  the 
newer  teaching,  the  disease  is  a  centrip- 
etal parenchymatous  atrophy  or  degen- 
eration of  sensory  neurons  followed  sec- 
ondarily by  sclerosis,  due  to  nutritional 
disturbances,  which,  according  to  Marie. 


affect  first  the  ganglia  on  the  posterior 
roots. 

These  ganglia,  it  will  be  remembered, 
are  the  trophic  centres,  not  only  for  the 
sensory  nerves,  but  for  the  neuraxons,  or 
axis-cylinder  processes,  of  the  dorsal 
columns  of  the  cord.  The  neuron  of  the 
posterior  spinal  ganglia  is  a  flask-shaped 
body,  having  an  axis-process,  or  neu- 
raxon,  which  divides  into  two  branches, 
one  of  which  passes  within  the  nerve- 
sheath  to  the  periphery,  forming  an  ar- 
borized or  brush-like  net-work  of  distri- 
bution in  the  skin  or  muscle-spindles. 
The  other  branch  passes,  with  the  pos- 
terior root,  into  the  cord,  dividing  there 
into  two  branches,  one  of  which  ascends, 
while  the  other  descends,  in  the  posterior 
column.  From  both  of  these  branches 
smaller  fibres  are  given  off  which  termi- 
nate in  the  posterior-horn  gray  matter. 
Some  of  these  smaller  fibres  are  short, 
others  quite  long,  extending  as  far  as  the 
medulla,  where  they  end  in  terminal  ar- 
borizations. Marie  divides  these  fibres 
j  into  three  sets: — 

1.  Short  fibres  which  pass  directly  into 
the  posterior  horns  after  entering  the 
cord. 

2.  Fibres  of  medium  length  which  run 
upward  in  the  cord,  some  of  them  ending 
in  the  middle  posterior  horn,  others  pac- 
ing into  Clarke's  column.  These  fibres 
are  contained  in  the  fasciculus  cuneatus 
of  Burdach. 

3.  Long  fibres  coming  chiefly  from  the 
roots  of  the  cauda  equina,  passing  theme 
the  full  length  of  the  cord  to  the  medulla 
and  forming  the  fasciculus  gracilis  of 
Gall. 

Marie's  theory  is  as  follows:  "The 
changes  found  in  the  tabetic  spinal  cord 
are  not  the  result  of  a  primary  systemic 
myelopathy:  they  are  the  expression  of  a 
progressive  degeneration  of  the  posterior- 
I  root  fibres;  these  medullary  changes  in 


LOCOMOTOR  ATAXIA.  PATHOLOGY. 


447 


tabes  occur  in  segments,  while  each  dis-  I 
eased  posterior  root  furnishes  a  new  con- 
tingent of  degenerated  fibres  to  the  spinal  ; 
cord."  The  initial  cord-lesion  is  found  j 
in  the  dorsal-root  zone  and  the  Spitzka- 
Lissauer  tract,  due,  Marie  believes,  to  de- 
generation through  the  medium  of  the  j 
short  (1)  fibres.  The  degeneration  in 
the  columns  of .  Burdach  and  Clarke's 
columns,  which  is  usually  proportionate 
in  degree  to  the  duration  of  the  disease, 
occurs  through  the  medium  of  the  fibres  j 
of  the  second  group.  The  sclerosis  ob- 
served in  the  columns  of  Gall  he  at- 
tributes to  the  degeneration  of  the  long  j 
fibres  of  Group  3.  Primary  disease  of 
the  ganglia  of  the  dorsal  roots  affords  the 
explanation  for  the  peripheral  neuritis, 
which  is  parenchymatous  and  not  inter- 
stitial, and  is  the  result  of  disease  of  the 
trophic  centre  of  the  peripheral  nerve  in 
the  posterior  ganglia.  Marie,  while  main- 
taining this  view,  most  strenuously  ad- 
mits that  no  evidence  whatever  of  disease 
of  the  spinal  ganglia  is  found  in  some 
cases,  but  it  is  quite  possible  to  assume 
that  very  subtile  and  slight  trophic 
changes  at  this  point,  although  unrecog- 
nizable, are  sufficient  to  produce  the 
changes  in  the  distal  arborizations  of  the 
sensory  neuraxons  in  the  muscle-plates 
and  skin,  and  in  the  cord  which  are  far- 
thest removed  from  their  nutritional 
centres,  which  changes  give  rise  to  the 
lightning  pains,  the  diminished  knee- 
jerks,  pupillary  changes,  the  vesical  and 
sexual  symptoms,  and  other  sensory  and 
trophic  disturbances  which  mark  the  in- 
cipient stages.  The  studies  of  Dejerine, 
Wallenberg,  Rousoni,  Blocq,  Trepinski, 
Obersteiner,  and  Redlich,  as  well  as  the 
very  interesting  and  important  observa- 
tions of  Sherrington,  Batten,  and  others 
as  to  the  relations  in  health  and  disease 
of  the  distal-nerve  arborization  in  muscle- 
plates  and  muscle-spindles  to  the  muscu- 


lar sense  and  its  perversions,  are  all  dis- 
|  tinctively  corroborative  of  this  theory. 

The  relationship  of  syphilis  etiolog- 
i  ically  occurs,  according  to  the  views  of 
Obersteiner  and  Redlich,  through  the 
presence  of  thickening  of  the  pi  a,  from 
j  old  leptomeningitis  presumably,  which, 
by  compressing  the  dorsal-root  fibres  at 
a  point  of  lessened  resistance,  leads  to 
their  degeneration.  Further  discussion  of 
this  very  important  subject,  while  exceed- 
|  ingly  interesting,  would  be  without  pres- 
ent advantage  in  the  absence  of  further 
proof,  which  is  needed  before  a  final  ac- 
|  ceptance  of  these  views  in  their  entirety 
is  admissible. 

Tabes  is  being  regarded  less  and  less  as 
a  disease  limited  to  the  cord,  and  it  is 
even  doubtful  whether  the  lesions  of  the 
posterior  columns  are  primary.  The  tend- 
ency of  accumulating  facts  is  to  the  effect 
that  they  are  secondary  to  neuritis  of  the 
posterior  roots;  that  tabes  presents  more 
and  more  the  appearance  of  peripheral 
disease  of  the  sensory  and  motor  nerves 
and  the  nerves  of  special  sensation.  De- 
jerine (La  Med.  Mod.,  Mar.  20,  '90). 

In  a  great  number  of  tabetic  spinal 
cords  the  affection  of  the  posterior  col- 
umns and  of  the  posterior  horn  in  this 
disease  conforms  itself  in  every  detail  to 
the  intraspinal  course  of  the  posterior- 
root  fibres.  Redlich  (Psych.  Jahrbucher, 
vol.  ii,  '92). 

Tabes  is  to  be  considered  as  a  primary 
sclerosis  by  successive  degeneration  of  the 
nerve-fibres  and  cells.  Its  progressive 
character  admits  of  the  supposition  that 
a  poison  may  be  present  in  the  body 
which  constantly  influences  the  diseased 
tissue  (toxin  theory).  Dana  (N.  Y.  Med. 
Jour.,  Jan.  9,  '92). 

The  causative  condition  of  tabetic  dis- 
ease of  the  spinal  cord  is  to  be  found  in 
a  compression  of  the  posterior  roots,  at 
their  point  of  penetration  into  the  spinal 
cord,  with  consecutive  ascending  degener- 
ation of  their  intramedullary  prolonga- 
tions. Obersteiner  and  Redlich  (Arbeiten 
aus  den  Inst.  f.  Anat.  u.  Phys.  des  Cen 
tralnerv.  in  Wien,  '94). 

There  is  a  constriction  or  snaring  of  the 


LOCOMOTOR  ATAXIA.  PATHOLOGY. 


posterior  roots  by  a  process  which  may  be 
termed  inflammatory,  causing  degenera- 
tion of  the  posterior  columns;  but  the 
point  of  the  tightening  pressure,  however, 
is  not  established  at  the  spot  where  the 
root  extends  through  the  pia  mater,  but 
rather  at  the  passage  of  the  outer  spinal 
meninges,  where  the  dura  mater  and 
arachnoids  lie  closely  against  the  pair  of 
roots,  in  funnel  shape,  inclosing  the  same 
as  far  as  the  spinal  ganglion.  At  this 
point  in  tabes  is  found  a  perineuritis 
with  nuclear  proliferation  and  consecu- 
tive sclerosis.  This  occasions  a  circular 
tightening  of  the  roots  by  which  these, 
and  particularly  the  posterior  roots,  are 


as  yet  undetermined.  H.  Obersteiner, 
Assoc.  Ed.,  Annual,  '95. ] 

Pathological  changes  demonstrated  in 
the  cerebellum  in  all  of  the  six  cases  of 
tabes  personally  examined — for  instance, 
atrophy  of  the  nerve-cells  in  the  corpus 
dentatum  and  degeneration  of  the  medul- 
lary fibres  in  the  lobules.  Tellinek  (Deut. 
med.  Zeit.,  Mar.  26,  '94). 

[Degeneration  of  the  spinal  trigeminus 
root  in  tabes  is  not  by  any  means  rare, 
and  the  ascending  root  of  the  glosso- 
pharyngeus  nearly  always  degenerates 
simultaneously.  H.  Obersteixer,  Assoc. 
Ed.,  Annual,  '95.] 

The  condition  of  tabetic  arthropathies 


\  •?•'.(  '/re- 


view of  a  normal  posterior  lumbar  root  at  its  point  of  entrance  into  the  spinal  cord. 
At  the  spot  where  the  root  is  tightly  compressed  by  the  pia  mater  it  appears  darker, 
while  the  medullary  sheaths  are  much  thinner  or  are  totally  absent.  {Obersteiner.) 


very  much  injured.  Nageotte  (Bull,  de  , 
la  Soc.  Anat.,  Nov.  10,  '94). 

Changes  found  by  Nageotte  frequently 
occur  in  tabes  at  the  point  indicated,  but 
they  are  of  no  importance  as  far  as  the 
degeneration  of  the  posterior  roots  is  con- 
cerned, since  the  latter  show  the  same  de-  I 
gree  of  degeneration,  both  in  front  of  and 
behind  this  point,  in  a  longitudinal  sec- 
tion. Obersteiner  (Arbeit,  a.  d.  Inst.  f. 
Anat.  u.  Phys.  d.  Centralnerv.,  No.  3,  '95). 

[Modern  views  concerning  the  condi- 
tion of  tabetic  disease  of  the  spinal  cord 
may  be  summarized  as  follows:  That  we 
have  here  to  deal  with  a  secondary  de- 
generation of  the  intramedullary  pro- 
longations of  the  posterior  roots,  the 
initial  point  of  this  degeneration  being 


is  one  of  trophic  degeneration  without  in- 
llammation.  Parker  Syms  (N.  Y.  Med. 
Jour.,  Jan.  19,  '95). 

Literature  of  '96-'97-'d%. 

[The  pathogeny  of  tabetic  arthropathy 
is  still  shrouded  in  mystery.  Doubtless 
the  interchange  of  action  between  the 
sensory  and  vasomotor  nerve-functions  is 
disturbed  by  the  pathological  conditions 
in  the  nervous  apparatus,  but  it  is  still 
a  question  whether  the  neurotic  arthrop- 
athies are  referable  to  such  a  disturb- 
ance; perhaps  there  is  merely  a  condi- 
tion of  ordinary  arthritis  deformans 
which  has  undergone  a  decided  modifica- 
tion owing  to  the  lesion  of  the  nervous 


LOCOMOTOR  ATAXIA.  COMPLICATIONS. 


449 


system.    H.  Obersteiner,  Assoc.  Ed., 
Annual,  '96.] 

The  lesion  of  tabes  has  its  origin  in  the 
posterior  roots  just  at  their  point  of  union 
with  the  cord.  This  is  anatomically  a 
locus  minoris  resistentice ;  what  precise 
exciting  cause  of  the  change  is  has  to  be 
decided.  Redlich  (Die  Pathol,  der  Tab., 
Hinter.  ein  Beit,  zur  Anat.  und  Pathol, 
der  Rucken.,  p.  6,  205,  Jena,  '97). 

Tabetic  processes  classified  as  intersti- 
tial and  parenchymatous.  The  former  is 
regarded  as  entirely  secondary  to  the 
latter,  which  is  the  primitive  change.  It 
affects  the  posterior  roots  and  posterior 
columns,  but  leaves  the  intervertebral 
ganglia  intact.  The  change  affects  the 
myelin  sheath,  bringing  about  a  segmen- 
tation and  granular  degeneration,  result- 
ing in  atrophy.  The  nuclei  of  the'  nerves 
are  not  multiplied,  but  the  exact  condi- 
tion of  the  axis-cylinder  was  not  deter- 
mined. It  probably  remains  more  or  less 
intact  for  a  long  time.  The  evolution  of 
tabes  follows  two  types:  the  benign  and 
the  grave.  In  the  latter  the  lesion  is  in 
the  cord,  resulting  in  very  rapid  destruc- 
tion of  the  endogenous  zones  of  the  pos- 
terior columns,  both  ascending  and  de- 
scending. In  the  former,  on  the  other 
hand,  the  lesion  is  in  the  posterior  roots, 
outside  the  cord,  and  has  little  tendency 
to  spread.  It  is  these  that  especially  ex- 
hibit pains,  while  numbness  and  tingling 
indicate  rather  an  affection  of  the  cord. 
Philippe  (Arch,  de  Neurol.,  Sept.,  '97). 

In  locomotor  ataxia  there  is  a  lowered 
vitality  of  the  nervous  apparatus,  in- 
herited or  acquired,  resulting  in  defective 
nutrition  of  the  neurons.  The  neurons 
are  the  first  to  exhibit  signs  of  malnutri- 
tion in  parts  farthest  removed  from  their 
affected  nutrition-centres  in  the  posterior 
spinal  ganglia,  viz. :  the  cutaneous  spinal- 
cord  arborizations,  respectively.  Mottler 

(N.  Y.  Med.  Jour.,  Oct.  15,  '98). 

Complications. — Locomotor  ataxia  is 
quite  frequently  encountered  in  associa- 
tion with  general  paresis.  Either  of  the 
two  may  appear  as  the  primary  disease, 
the  other  occurring  in  such  cases  as  a 
complication.  Hemiplegia  is  also  not 
very  uncommon.  Through  an  extension 
qf  the  disease-process  other  areas  of  the 

4- 


cord  may  be  involved,  and  symptoms  of 
lateral  sclerosis,  progressive  muscular 
atrophy,  etc.,  may  be  added  to  the  origi- 
nal picture.  Phthisis,  heart  disease,  and 
nephritis  are  occasionally  found  co- 
existent, though  not  in  any  essential  re- 
lationship. 

In  a  male  patient  the  very  unusual 
combination  of  tabes  with  paralysis  agi- 
tans  noted.  Placzek  (Deut.  med.  Woch., 
July  7,  '92). 

Atypical  cases  of  tabes  in  which,  with 
the  sudden  appearance  of  hemiplegia  on 
the  left  side,  there  were  also  pronounced 
symptoms  of  paralysis  agitans.  Raichline 
(Jour,  de  Med.,  July  28,  '95). 

Dementia  paralytica  and  true  tabes  are 
only  rarely  combined,  but  the  former 
affection  may  begin  with  spinal  symp- 
toms which  simulate  tabes;  it  is  then 
merely  a  pseudotabetic  process  with  a 
different  condition  in  the  spinal  cord. 
Joffroy  (Nouv.  Icon,  de  la  Salpetriere, 
No.  1,  '95). 

Exophthalmic  goitre  and  diabetes  have 
also  been  observed. 

The  relation  existing  between  tabes 
and  diabetes  may  vary  in  character;  dia- 
betes being  present,  certain  symptoms  of 
tabes  may  occur,  or  during  the  course  of 
tabes  sugar  may  appear  in  the  urine. 
There  is,  besides,  relation  between  true 
tabes  and,  true  diabetes,  through  the  fact 
that  these  diseases  occur  in  various  per- 
sons of  the  same  family,  in  consequence 
of  an  hereditary  nervous  taint,  both  ap- 
pearing at  times  in  the  same  subject. 
Blocq  (Revue  Neurol.,  Apr.  30,  '94). 

The  association  of  exophthalmic  goitre 
with  tabes  is  more  than  a  mere  coinci- 
dence. It  is  due  to  bulbar  disturbances, 
possibly  from  congestive  hypersemia. 
Marie  (La  Sem.  Med.,  Dec.  19,  '88). 

Two  cases  in  which  tabes  was  combined 
with  Basedow's  disease.  Thimotheeff 
(These  de  la  Faculte  de  Paris,  '93). 

In  a  case  of  tabes  combined  with  Base- 
dow's disease  there  was  found  degenera- 
tion of  the  ascending  roots  of  the  tri- 
geminus and  of  the  glossopharyngeal 
nerve.  Marie  and  Marinesco  (Revue 
Neurol.,  May  30,  '93). 

-29 


450 


LOCOMOTOR  ATAXIA.    PROGNOSIS.  TREATMENT. 


Prognosis. — The  disease  has  been  here-  I 
tofore  considered  essentially  chronic  and 
progressive  and  the  prognosis  as  regards 
cure  extremely  unfavorable.  The  degree 
to  which  the  newer  discoveries  and  corre- 
lated teachings  in  pathology  will  modify 
this  conclusion  has  not  yet  been  fully  de- 
termined. It  can,  at  best,  affect  the  prog- 
nosis favorably  only  when  the  disease  is 
recognized  and  properly  treated  promptly 
and  in  its  incipiency.  Well-established 
locomotor  ataxia  will,  in  all  probability, 
remain,  as  heretofore,  a  chronic  progress- 
ive practically  incurable  affection. 

The  duration  of  the  disease  is  very 
variable,  extending  over  a  period  from 
twenty  to  thirty  years  in  some  instances. 
It  is  rarely  the  cause  of  death  per  se, 
a  fatal  termination  occurring  usually 
through  the  medium  of  some  intercur- 
rent affection,  such  as  cystitis,  pyelitis, 
trophic  disorders,  hypostatic  pneumonia 
or  bronchitis,  or  a  profound  asthenia. 

Much  in  the  way  of  symptomatic  relief 
may  be  promised  from  intelligent  treat- 
ment, and  in  some  cases  long  periods  of 
arrested  progress  may  be  obtained.  Co- 
ordination can  be  materially  improved 
and  the  pains  and  crises  relieved.  Spon- 
taneous amelioration  of  symptoms  may 
occur  and  spontaneous  remissions  in  the 
progress  of  the  disease  have  been  fre- 
quently noted,  but  such  results  are  much 
more  positively  assured  from  treatment. 
Usually  the  pains  tend  to  become  pro- 
gressively less  as  the  disease  advances, 
the  explanation  being  obvious  in  a  pro- 
gressive diminution  in  sensory  function. 

Less  easy  of  explanation,  but  none  the 
less  a  fact,  is  the  lessening  and  sometimes 
marked  improvement  in  the  ataxic  and 
painful  symptoms  which  ai tends  the  on- 
set of  blindness.  The  greater  amount  of 
rest — enforced  rest — affords  a  probable 
partial  explanation.  The  development 
of  severe  trophic  symptoms  is  an  omen  I 


!  of  evil  and  may  be  the  precursor  of  the 
end.  Pseudoparalytic  or  actual  paralytic 
helplessness  may  develop  in  the  late 
stages  and  superinduce  a  fatal  asthenia. 
Cases  with  well-marked  and  frequently- 
recurring  crises,  especially  gastric,  car- 
diac, and  respiratory,  are  said  to  run  a 
shorter  average  course.  The  etiological 
element  in  individual  cases  does  not  ap- 
parently modify  the  prognosis  to  any 
appreciable  extent.  Freedom  from  want 
and  worry,  on  the  other  hand,  are  materi- 
ally advantageous  to  the  possessor  who  is 
a  victim  of  this  disease.  In  my  personal 
experience,  which  is,  however,  insuffi- 
cient for  positive  deduction,  the  disease 
runs  a  far  more  rapid  course  in  women 
than  in  men. 

Treatment.  —  There  is  no  specific 
known  to  be  effective  in  curing  locomotor 
ataxia,  and  this  is  true  even  of  the  cases 
positively  due  to  syphilis.  Iodide  of 
potassium  and  mercury  in  various  forms 
alone  or  in  combination  have  proved 
equally  inefficient,  at  least  as  regards 
anatomical  cure,  though,  occasionally,  in 
acute  cases  especially,  an  arrest  of  prog- 
ress has  been  attributed,  and  probably 
correctly,  to  these  agents.  In  cases  in 
which,  by  intuition  or  good  fortune, 
rather  than  by  applied  diagnosis,  the  dis- 
ease has  been  recognized  in  its  very  in- 
cipiency, the  prompt  and  proper  adminis- 
tration of  either  of  these  drugs  might 
prove  positively  curative  and  is  certainly 
worthy  of  employment.  The  uncertainty 
of  diagnosis  would,  however,  render  con- 
clusions as  to  the  curative  value  of  these 
drugs  at  least  a  problem. 

Cases  of  tabes  of  rapid  course  treated 
early  by  large  doses  of  mercury  (inunc- 
tions) and  potassium  iodide,  with  persis- 
tent and  complete  cures;  4  cases  cited. 
Germeix  (Archives  de  M€d.  et  de  Pharm. 
Milit.,  dan..  '89). 

Mercury  accomplishes  nothing  in  tabes. 
The  irregular  course  of  the  disease  gives 


LOCOMOTOR  ATAXIA.  TREATMENT. 


451 


rise  to  the  illusions  concerning  its  efficacy. 
Charcot  (La  Sem.  Med.,  June  4,  '90). 

Mercury  may  modify  the  syphilitic  le- 
sions  so  as  to  possibly  hold  the  tabetic 
trouble  to  a  milder  grade,  and,  therefore, 
should  be  tried,  but  we  should  not  expect 
it  to  affect  the  tabetic  degenerations  al- 
ready existing.  Striimpell  (Munch,  med. 
Woch.,  Sept.  30,  '90). 

Case  of  locomotor  ataxia  of  syphilitic 
origin  cured  by  specific  treatment. 
Gaucher  (La  Sem.  Med.,  July  16,  '90). 

The  idea  that  antisyphilitic  treatment 
in  tabes  is  useless  or  even  hurtful  is  erro- 
neous. Personal  improvement  of  one  or 
several  symptoms  found  in  fifty-eight  of 
seventy-one  cases  of  tabes,  after  the  use 
of  mercury;  there  were  no  results  in 
eleven  cases,  and  only  in  two  did  aggra- 
vation of  the  symptoms  occur.  Heidel- 
berg (Berliner  klin.  Woch.,  Nos.  15,  20. 
'93). 

Marked  improvement  in  an  already  ad- 
vanced case  of  tabes,  by  the  administra- 
tion of  large  doses  of  iodide  of  sodium, 
as  high  as  2  drachms  per  day.  Max 
Weiss  (Centralb.  fiir  die  Gesammte  Ther.. 
Feb.,  '94). 

There  is  little  if  any  evidence  in  clin- 
ical experience  tending  to  confirm  the 
claims  advanced  as  to  the  curative  merits 
of  the  salts  of  silver  and  gold,  of  ergot,  of 
arsenic,  or  of  the  many  other  vaunted  ; 
specifics  which  appear  in  the  older  litera- 
ture of  this  disease. 

Eleven  tabetic  patients  treated  by  hyp- 
odermic injection  of  nitrate  of  silver. 
There  was  hardly  any  appreciable  im- 
provement except  in  1  case,  in  which  the 
improvement  was  very  decided  respecting  j 
the  pains,  ataxia,  and  vesical  and  rectal  j 
symptoms.  Rosenbaum  (Deut.  med.- 
Zeit.,  May  15,  '90). 

Phosphate  of  sodium  used  in  a  number 
of  eases  with  surprising  results.  A  solu- 
tion of  1  •/<  grains  of  the  salt  in  15  Va 
minims  of  cherry-laurel  water  is  injected 
close  beside  the  lumbar  vertebral  column. 
According  to  the  severity  of  the  disease, 
one  or  two  injections  are  made  daily. 
After  twenty-five  applications  the  im- 
provement is  very  noticeable,  and  after 
fifty  very  pronounced.  Forbes  Winslow 
(Lancet,  Nov.  18  ct  scq.,  '93). 


Happy  results  attained  with  phosphate 
of  sodium.  A.  Cordes  (Lancet,  Nov.  25, 
'93). 

In  case  of  tabes  an  injection  of  Koch's 
tuberculin  was  given,  and  repeated  in 
two  days;  the  treatment  followed  for 
three  weeks.  Pains  were  increased  at 
first,  then  rapidly  diminished,  until,  at 
the  end  of  three  weeks,  they  had  entirely 
gone.  Co-ordination  was  much  improved, 
and  his  strength  greatly  increased.  An- 
other case  showed  great  improvement 
under  similar  treatment.  Neilson  (Med. 
and  Surg.  Reporter,  May  30,  '91). 

Great  stress  laid  on  the  use  of  warm 
baths  (temperature,  95°  to  86°  F.),  the 
duration  of  which  should  be  from  five  to 
twenty  minutes.  Three  kinds  of  baths 
are  employed:  (1)  the  simple  warm 
bath;  (2)  brine-baths  containing  C02; 
(3)  sweating-baths  and  vapor-baths.  The 
first  and  third  kinds  are  suitable  in  the 
early  stages  of  tabes,  the  second  in  the 
more  advanced  stage.  Ley  den  (Inter, 
klin.  Rund.,  Dec,  '89). 

Plea  for  the  cold-water  treatment  of 
spinal  diseases.  Cold  affusion  to  the 
lower  extremities  is  of  value,  these  parts 
having  been  previously  warmed  by  the 
hot  pack  or  by  steam-baths.  The  cold 
should  not  be  applied  for  more  than  a 
minute,  after  which  the  parts  are  dried 
and  covered  for  half  an  hour  with  dry 
blankets.  This  treatment  has  proved  es- 
pecially efficacious  in  tabes.  R.  von 
Hoesslin  (Balneol.  Centralb..  Oct.  16,  '91). 

In  locomotor  ataxia  lukewarm  baths, 
with  pine-needle  extract,  or  half-baths 
with  affusion,  are  indicated.  Hot  sand- 
or  water-  bags  are  sometimes  applied  con- 
tinuously to  the  spine  for  one  or  two 
hours,  with  the  purpose  of  increasing  the 
temperature  and  circulating  activity  of 
the  cord.   Dana  (Dietetic  Gaz.,  Dec,  *91). 

Use  of  suggestion  proposed  for  tabes. 
Without  its  being  in  any  way  possible  to 
influence  the  organic  changes  in  the  nerv- 
ous system,  one  may  yet  be  able  to  re- 
move a  number  of  functional  disturbances 
and  to  materially  help  the  patient.  Beri- 
llon  (Congres  Frangais  des  Med.  Alienists 
et  Neurol.,  '95). 

In  the  majority  of  apparently-organic 
nervous  affections  there  is  also  a  func- 


452  LOCOMOTOR  ATAXIA.  TREATMENT. 


tional  psychical  factor;  this  explains  the 
wonderful  improvement  in  organic  cere- 
bral lesions  under  hypnotic  influence, — 
i.e.,  suggestion.  H.  Obersteiner  (Wiener 
klin.  Woch.,  No.  17,  '95). 

The  method  of  suspension,  while 
effective  in  exceptional  instances  in 
modifying,  at  least,  temporarily,  certain 
obtrusive  symptoms,  has  not  survived 
the  test  of  time,  and,  indeed,  is  to-day 
condemned  as  often  positively  harmful. 

Suspension  may  cause  untoward  effects 
in  the  early  stages  of  tabes,  as  by  this 
means  the  meningeal  hyperemia  is 
heightened.  Of  all  the  symptoms  of 
tabes,  impotence  is  the  one  apparently 
most  influenced:  Aravena  (Boletin  de 
Med.  de  Santiago,  Oct.,  '92  to  Feb.,  '93). 

The  lancinating  pains  and  crises  occa- 
sioned by  the  pressure  upon  the  nerve- 
roots  and  even  the  transitory  improve- 
ment caused  by  suspension  and  nerve- 
stretching,  are  explainable  through  the 
fact  that  the  tension  brings  about  a  loos- 
ening of  the  compressed,  swelled  con- 
nective tissue.  Obersteiner  and  Redlich 
(Arbeit,  aus  den  Inst.  f.  Anat.  u.  Phys. 
des  Centralnerv.  in  Wein,  '94). 

Suspension  considered  as  a  useful  meas- 
ure in  a  number  of  cases;  certain  symp- 
toms are  improved,  as,  for  instance,  pains, 
sexual  weakness,  and  incontinence.  De 
Forest  Willard  and  Guy  Hinsdale  (Med. 
News,  Nov.  24,  '94). 

Case  of  a  tabetic  patient  Avho  was 
obliged  to  use  a  wheel-chair  ;  suspension 
was  resorted  to  every  other  day  during  a 
long  period  (several  years).  After  from 
fifteen  to  eighteen  months  he  was  able  to 
walk  with  two  canes,  and  after  three 
years  he  could  walk  alone,  play  croquet, 
etc.  The  bladder  and  rectal  symptoms  j 
also  disappeared  under  this  treatment,  j 
Hugh  Cuthbertson  (Canadian  Pract., 
Nov.,  '94). 

Literature  of  '96-97-'9&. 

The  following  points  given  as  the  chief 
aim  in  the  treatment  of  tabes:    Active  I 
antisyphilitic  treatment  if  the  indication 
exists,  the  use  of  tonics,  and  electricity;  1 
hydrotherapy  in  its  various  tonic  forms,  1 


the  use  of  electrotherapy  and  suspension, 
care  being  taken  not  to  neglect  symptom- 
atic treatment.  Later,  if  the  indica- 
tions still  exist  for  active  antisyphilitic 
treatment  it  is  to  be  used,  although  such 
good  results  cannot  be  expected  from  it. 
Careful  regulation  of  the  diet  should  be 
insisted  upon,  and  hydrotherapy,  elec- 
tricity, with  gymnastics,  suspension,  and 
psychical  treatment  should  be  utilized. 
If  the  disease  is  very  far  advanced  and 
the  patient  is  much  incommoded  in  his 
movements,  it  is  important  to  maintain 
his  mental  tone  by  every  encouraging 
method  that  one  possesses,  and  to  use 
medication  which  will  combat  the  dis- 
agreeable or  painful  symptoms.  Erb 
(Revue  de  Ther.,  May  1,  '97). 

By  causing  a  sitting  patient  to  bend 
forward  strongly  with  the  hands  out- 
stretched, a  true  strong  elongation  of  the 
spinal  cord  to  the  extent  of  about  2/5 
inch  takes  place,  and  this  elongation 
occurs  mostly  in  the  lumbar  region.  The 
writers  have,  therefore,  constructed  an 
apparatus  so  that  the  bending  may  be 
brought  about  forcibly  without  interfer- 
ing with  the  breathing  or  circulation.  It 
was  tried  in  the  second  stage  of  the  dis- 
ease, in  thirty-nine  men  and  eight 
women ;  cases  of  very  long  duration  were 
excluded  as  well  as  cases  of  very  rapid 
onset,  or  if  in  the  third  or  paralytic  stage. 
Good  results  were  obtained  in  half  the 
cases;  the  sensory  irritations  and  light- 
ning pains  were  improved,  retention  of 
urine  was  relieved,  but  incontinence  was 
less  influenced.  Almost  always  the  gait 
improved,  and  ten  patients  were  able  to 
walk  again  alone;  on  the  eyes  and  bulbar 
symptoms  the  stretched  had  very  little 
influence.  Ten  patients  were  not  bene- 
fited. Each  stretching  was  kept  up  for 
eight  or  twelve  minutes,  and  repeated 
fifteen  to  twenty  times.  Improvement 
showed  itself  mostly  at  the  tenth  to  the 
fifteenth  sitting.  The  treatment  was 
never  continued  for  longer  than  three  or 
four  months  or  forty  to  fifty  sittings. 
Gilles  de  la  Tourette  and  Chipault  (Prog. 
Med.,  p.  278.  '97). 

In  the  treatment  a  favorable  impres- 
sion was  gained  from  the  use  of  large 
quantities  of  water  for  purposes  of  flush- 


LOCOMOTOR  ATAXIA.  TREATMENT. 


453 


ing  out  the  system.  Patients  are  in- 
structed to  drink  from  5  to  7  pints  of 
water  daily.  Hydrotherapy,  especially 
warm  baths,  electricity,  massage,  and 
other  mechanical  movements,  including 
suspension  treatment,  are  valuable.  W. 
H.  Riley  (Jour.  Nerv.  and  Mental  Dis., 
Sept.,  '98). 

The  therapeutic  life  of  the  animal  ex- 
tracts in  this  disease  was  equally  short 
and  inglorious.  In  the  absence  of  any 
specific  our  efforts  are  limited  to  two  in- 
dications: the  retardation  in  progress  of 
the  disease  and  the  palliation  or  control 
of  symptoms.  Much  can  be  done  in  both 
directions.  Three  remedial  measures 
stand  out  conspicuously  in  a  host  of  fail- 
ures as  having  a  certain  and  established 
value.  These  three  are  rest,  electricity, 
and  the  Frenkel  method  of  "re-educa- 
tion." Conjointly  and  intelligently  em- 
ployed, the  results  are  positive  and  at 
least  relatively  satisfactory.  The  degree 
of  rest  necessarily  varies.  In  the  incipi- 
ent stage  the  severity  and  frequency  of 
the  pains  and  other  sensory  symptoms 
should  be  the  guide.  Five  or  six  weeks 
of  absolute  rest  in  bed  is  ordinarily  suffi- 
cient. The  return  to  active  exercise 
should  always  be  tentative  and  gradual 
and  for  months  or  even  years  the  amount 
of  physical  exercise  should  be  carefully 
guarded.  Any  evidence  of  an  aggrava- 
tion of  the  disease  should  be  interpreted 
as  a  danger-signal,  demanding  a  return 
to  absolute  rest.  In  the  ataxic  stage  the 
same  rule  should  apply,  though  with  less 
rigor  perhaps,  since  the  results  to  be  ob- 
tained are  less  important.  I  have  seen 
the  pains,  the  ataxia,  the  disturbances  in 
sphineteric  control  and  the  various  crises 
either  greatly  lessen  in  severity  or  en- 
tirely disappear  from  prolonged  absolute 
rest.  Next  in  order  to  rest  is  galvanism. 
Of  the  value  of  static  electricity  I  have 
no  personal  knowledge.  Farad  ism  in  my 
experience  is  quite  often  and  perhaps  al- 


ways positively  harmful.  Galvanism 
should  be  employed  daily.  The  current 
should  not  exceed  at  first  5  milliamperes. 
The  seances  should  at  first  be  limited  to 
ten  or  twenty  minutes,  gradually  length- 
ened to  one  or  even  two  hours,  daily. 
The  electrodes  (Erb)  should  be  applied 
to  the  spine,  thoroughly  wet,  of  course; 
one  over  the  upper  dorsal  region,  the 
other  over  the  upper  sacral  spine.  The 
selection  of  the  pole  is  immaterial  in  my 
experience.  Occasionally  it  is  of  advan- 
tage, if  the  pains  are  severe  or  the  ataxia 
of  station  or  gait  extreme,  to  apply  the 
electrodes  one  under  the  sole  of  each 
foot,  the  current  making  the  direct  cir- 
cuit of  the  nerves  chiefly  affected. 

Literature  of  '96-'97-'98. 

Rest  is  the  most  important  part  of  the 
treatment.  In  the  severer  cases  the  pa- 
tient should  be  in  bed  for  weeks,  whereas 
in  the  milder  ones  a  few  hours  a  day  in 
bed  may  be  sufficient.  The  amount  of 
rest  required  varies  greatly  with  different 
individuals.  Antisyphilitic  treatment 
often  proves  most  valuable.  Landon 
Carter  Gray  (K  Y.  Med.  Jour.,  Mar.  12, 
'97). 

More  than  one-half  the  cases  of  loco- 
motor ataxia  may  be  almost  completely 
arrested  in  the  incipient  period  of  the 
disease,  and  nearly  all  are  more  or  less 
amenable  to  treatment,  if  this  is  insti- 
tuted before  the  patient  becomes  greatly 
exhausted,  or  before  he  has  to  take  to  his 
bed.  J.  T.  Eskridge  (Charlotte  Med. 
Jour.,  Dec,  '98). 

A  rest  treatment  may  be  essential  for 
the  best  results  in  a  stubborn  advancing 
case.  Such  patients  should  never  exercise 
to  tire,  and  should  be  in  the  fresh,  dry 
air  much,  especially  at  great  altitudes. 
Massage  and  electricity  properly  applied 
are  most  valuable.  The  use  of  a  stimu- 
lating liniment  rubbed  well  over  the  sur- 
face of  the  body  has  proved  also  of  great 
value  in  stimulating  circulation. 

The  following  may  be  used:  — 


454  LOCOMOTOR  ATAXIA.  TREATMENT. 


I£  Ammonium  chloride,  3  drachms. 
Glycerin,  1  ounce. 
Tincture  of  capsicum,  1/2  ounce. 
Peppermint-water,  q.  s.  to  make  12 
ounces. 

M.  Rub  on  the  body  daily  for  twenty 
minutes,  with  massage.  Savary  Pearce 
(Therap.  Gaz.,  Oct.  15,  98). 

Frenkel's  method  consists  essentially 
and  in  principle  in  the  redevelopment, 
through  certain  exercises,  of  muscular 
co-ordination.  Its  usefulness  is  limited 
to  the  diminution  of  one  symptom 
(ataxia)  alone.  FrenkeFs  special  appa- 
ratus is  not  essential;  any  improvised  | 
procedure  which  observes  and  preserves 
the  principle  is  sufficient  and  equally 
effective. 

Method  of  treatment  recommended  for 
ataxia  of  the  upper  extremities.  It  is 
first  necessary  to  determine  which  mus- 
cular groups  are  affected,  and  it  is  par- 
ticularly important  to  know  whether  the 
shoulder-muscles  are  involved.  Ataxia 
in  the  last-named  region  usually  disap- 
pears readily  and  quickly  under  treat- 
ment, while  that  of  the  forearm  and  hand 
is  corrected  with  more  difficulty.  A 
series  of  different  apparatuses  constructed 
for  this  purpose;  the  patient  must,  for 
instance,  insert  a  number  of  pegs  in  a 
plate  provided  with  holes,  catch  swinging 
leaden  balls,  etc.  The  practice  should  be 
varied  so  that  the  patient  may  not  grow 
fatigued  and  lose  interest.  They  must 
also  resume  certain  occupations  (the 
fastening  of  their  clothes,  writing  with 
pen  and  ink,  piano-playing,  etc.)  in  case 
they  have,  for  greater  ease,  given  these 
up.  Even  in  pronounced  cases  of  ataxia 
very  good  results  may  be  expected;  the 
moral  effect  of  the  treatment  is  also  quite 
considerable.  The  improvement  noticed 
by  the  patient  and  the  physician  exerts  a 
powerful  influence  upon  the  disposition, 
sleep,  and  general  condition.  The  sensi- 
bility of  the  skin  and  muscles  also  im- 
proves under  this  treatment.  Frenkel 
(Zeitsch.  f.  klin.  Med.,  B.  28,  '95). 

Literature  of  '96-'97-'9$. 

Frenkel's  method  of  curing  ataxia  by 
re-education  of  the  movement  used  in 


nine  cases.  The  exercises  were  performed 
once  daily  for  about  half  an  hour,  and 
later  for  an  hour;  but  the  latter  time 
should  never  be  exceeded,  nor  should  the 
patient  be  tired.  In  three  of  the  cases  the 
ataxia  was  so  severe  that  there  was  total 
inability  to  walk  or  stand;  in  the  re- 
maining cases  the  ataxia  was  of  the 
middle  grade.  In  all  the  cases  there  was 
an  improvement  and  in  some  a  consider- 
able improvement.  Acute  cases  are  not 
benefited  until  the  case  has  reached  a 
more  stationary  period.  Hirschberg 
(Arch,  de  Xeurolog.,  vol.  ii,  Nos.  9-11, 
?96). 

For  exercising  the  upper  extremities 
the  following  directions  are  given:  Sit  in 
front  of  a  table,  place  the  hand  upon  it, 
then  elevate  each  finger  as  far  as  pos- 
sible; raise  the  hand  slightly,  extend,  and 
then  reflex  each  finger  and  thumb  as  far 
as  possible;  do  this  with  the  right  and 
then  with  the  left  hand.  Touch  with  the 
end  of  the  thumb  each  finger-tip  sepa- 
rately and  accurately;  then  touch  the 
middle  of  each  phalanx  with  the  tip  of 
the  thumb.  Sit  at  the  table  with  a  large 
sheet  of  paper  and  a  pencil ;  make  a  dot 
at  each  corner  of  the  paper  and  one  in  the 
centre,  and  draw  lines  from  the  corner 
dots  to  the  centre  dot,  first  with  the  right 
and  then  with  the  left  hand.  Put  ten 
coins  on  the  paper,  pick  them  up  and 
place  them  in  a  single  pile,  first  with  the 
right  and  then  with  the  left  hand. 

For  the  body  and  legs,  sample  exer- 
cises: Sit  in  a  chair,  rise  slowly  to  erect 
position  without  help  of  cane  or  arms  of 
chair  ;  then  sit  down  slowly :  stand  with 
cane,  feet  together;  advance  left  foot  and 
return  it,  then  the  same  with  right. 
Walk  slowly  ten  steps  forward  and  five 
back  with  help  of  canes.  Stand  without 
cane,  but  with  feet  a  little  apart  and 
the  hands  on  the  hips;  in  this  posi- 
tion stoop  down  by  flexing  the  knees, 
and  rise  slowly.  Stand  without  cane 
with  the  feet  separated:  raise  the  hands 
from  the  sides  above  the  head:  carry 
them  downward  and  forward,  and  try  to 
touch  the  toes.  Walk  along  a  fixed  line 
on  the  floor  by  help  of  cane,  placing  each 
foot  in  turn  oil  the  line:  then  repeat 
without  using  the  cane.  Most  of  these 
exercises    should    be    repeated  several 


LOCOMOTOR  ATAXIA.  TREATMENT. 


455 


times,  and  the  movements  should  be  made 
with  the  eyes  both  open  and  closed. 

Owing  to  disturbance  of  the  sensory 
paths  tabetics  have  lost  the  sense  of 
fatigue,  so  there  is  some  danger  in  over- 
doing the  treatment.  Two  things  are 
therefore  insisted  upon:  first,  every 
movement  must  be  done  with  the  great- 
est possible  exactitude,  and,  second,  the 
seance  should  not  last  more  than  eight  or 
ten  minutes,  and  no  more  than  two 
should  be  allowed  a  day. 

The  treatment  is  absolutely  contra-in- 
dicated in  cases  of  acute  or  subacute 
ataxia.  Frenkel  (Deutsche  med.  Woch., 
Dec.  17,  '97). 

All  cases  of  locomotor  ataxia  are  bene- 
fited by  the  exercise  treatment,  many  to 
the  degree  of  apparent  recovery,  unless 
there  are  special  contra-indications  to  the 
treatment. 

Contra  indications  are:  loss  of  vision, 
mental  impairment,  bone-  and  joint-  dis- 
ease, spasticity,  and  muscular  atrophy, 
the  presence  of  strong  irritation-symp- 
toms, rapid  progress  of  the  disease,  a  state 
of  great  exhaustibility,  and  serious  or- 
ganic disease. 

In  cases  of  anaemia,  poor  nutrition,  and 
lax  joints  these  conditions  should  be 
remedied  before  the  treatment  is  insti- 
tuted. 

The  conditions  most  favorable  for  the 
treatment  are:  a  stationary  or  almost 
stationary  state  of  the  disease,  good  gen- 
eral health,  intelligence,  hopefulness,  and 
perseverance. 

Light  cases  are  more  amenable  to  a 
(practical)  cure,  but  bad,  even  bedridden 
cases  often  give  brilliant  results. 

The  necessary  duration  of  treatment 
varies  from  a  month  or  more  for  the  light- 
est to  six  months  or  a  year  for  bad  cases, 
but  the  exercises  must  be  kept  up  in 
order  to  insure  the  continuance  of  the 
improvement. 

Success  of  treatment  depends  upon 
thorough  knowledge  of  the  method. 

Exercises  should  be  chosen  most  suit- 
able to  the  existing  ataxia,  and  every 
elTort  should  be  made  to  do  them  with 
the  greatest  precision. 

The  sense  of  fatigue  is  often  blunted  in 
ataxics,  while  overfatigue  injures  them. 
The  patient  should,  therefore,  be  guarded 


against  too  taxing  or  too  prolonged  exer- 
cises, or  other  unnecessary  efforts. 

To  obtain  most  benefit  from  the  treat- 
ment, the  constant  supervision  of  the 
physician,  at  least  in  its  early  periods,  is 
absolutely  necessary.  Zenner  (Cincin. 
Lancet-Clinic,  July  16,  '98). 

Not  very  obvious  results  noted  from 
antisyphilitic  remedies,  though  a  course 
of  them  should  always  be  tried  in  early 
cases.  A  short  course  of  arsenic  may  also 
be  advisable,  and  some  good  had  appeared 
to  result  now  and  then  from  the  use  of 
testicular  extracts.  Galvanism  along  the 
spine  and  hydrotherapeutic  treatment 
may  also  at  times  prove  of  service.  For 
the  ataxia,  the  best  results  are  obtained 
by  the  method  of  graduated  exercises  as 
practiced  by  Frenkel.  Trevelyan  (Quart. 
Med.  Jour.,  July,  '98). 

At  times  the  pains  are  so  severe  as  to 
require  immediate  relief.  Hot  sitz-baths, 
the  cold  pack,  ice-coils  to  the  leg  or  an 
ice-bag  or  the  cautery  to  the  spine,  may 
be  tried  with  or  without  any  one  of  sev- 
eral anodynes,  the  most  reliable  of  which 
are  antipyrine,  antifebrin,  phenacetin,  or 
codeine.  Morphine  should  be  employed 
as  a  last  resort  and  should  be  adminis- 
tered hypodermically. 

Exalgin  used  in  the  treatment  of  the 
lightning  pains  of  locomotor  ataxia; 
doses  of  from  4  to  12  grains  ordinarily 
employed.  Desnos  (Revue  Gen.  de  Clin, 
et  de  Ther.,  Feb.  15,  '91). 

Literature  of  '96-'97-'98. 

For  the  lightning  pains  of  locomotor 
ataxia  the  following  may  be  adminis- 
tered:— 

Antipyrine,  10  grains. 
Phenacetin,  3  grains. 
M.    Make  one  cachet. 
Sig. :    Take  one  cachet  every  fifteen 
minutes,  until  three  have  been  taken. 
Dejerine  (Med.  Mod.,  p.  797,  '97). 

For  the  relief  of  the  various  crises, 
symptomatic  remedies  arc  used.  Full 
doses  of  oxalate  of  cerium  usually  relieve 
promptly  the  vomiting  in  gastric  crises. 


456 


LOCOMOTOR  ATAXIA. 


LUPULUS. 


Heart-tonics,  such  as  caffeine,  strych- 
nine, etc.,  may  be  indicated  in  involve- 
ment of  the  vagus.  Cystitis  complicating 
locomotor  ataxia  may  be  treated  symp- 
tomatically  as  an  ordinary  cystitis  with 
relief.  Trophic  lesions  are  occasionally 
quite  intractable.  Strychnine  in  doses  of 
Vso  to  Vie  grain  will  at  times  retard  the 
progress  of  an  optic  atrophy.  Strychnine 
should,  however,  be  given  always  with 
caution  in  this  disease. 

Antipyrine  or  phenacetin,  15  grains  per 
dose,  recommended  when  optical  atrophy 
appears.  Hutchinson  (Archives  of  Surg., 
Jan.,  '94). 

Literature  of  '96-'97-'98. 

Case  in  which,  after  increasing  doses  of 
Fowler's  solution,  spinal-cord  stretching, 
and  static  electricity  had  failed,  strych- 
nine nitrate  was  used.  Strychnine 
nitrate,  1;  glycerin,  240;  water,  240; 
employed  hypodermically.  The  initial 
dose  was  grain  ( 10  drops  of  the  above 
solution),  which  was  increased  until  a 
dose  of  1/G  grain  was  reached;  next,  be- 
ginning with  the  initial  doses,  it  was  in- 
creased until  Vs  grain  was  attained. 
Again,  starting  with  the  initial  dose  it 
was  doubled,  and  trebled,  until  3/5  grain 
was  taken  at  a  dose.  Under  this  treat- 
ment the  pains  did  not  return,  the  man 
could  walk  with  the  aid  of  a  cane,  and 
his  general  symptoms  improved.  Emil 
Altaian  (Post-graduate,  No.  7,  '98). 

W.  B.  Pritchard, 

New  York. 

LUMBAGO.    See  Kheumatism. 

LUNGS.    See  Pulmonary. 

LUPULUS.— Lupulus  (humulus,  IT.  S. 
P.),  or  hops,  is  the  strobiles  or  fruit- 
cones  of  Humulus  lupulus  (order  Urti- 
cacece).  The  glandular  powder  adhering 
to  the  axis  and  bracts  is  called  lupulinum 
and  is  the  most  important  part  of  the 
plant.  Hops  contain  a  liquid,  volatile 
alkaloid  (lupuline  [?]),  a  bitter  prin- 


ciple (lupulinic  acid),  1  per  cent,  of  vola- 
tile oil,  9  to  18  per  cent,  of  resin,  3  to  4 
per  cent,  of  tannin,  a  fermentable  sugar, 
diastase,  and  a  small  amount  of  aspar- 
agin. 

Preparations  and  Doses.  —  Humulus 
(hops),  not  used  internally. 

Tinctura  humuli  (20  per  cent.),  1  to 
4  drachms. 

Infusum  humuli  (non-official,  4 
drachms  to  1  pint),  1  to  4  ounces. 

Lupulinum,  5  to  15  grains. 

Extractum  lupulinum  fluidum,  10  to 
30  minims. 

Oleoresina  lupulini,  2  to  7  minims. 

Therapeutics.  —  Stomachic  Tonic.  — 
Hops  is  useful  as  a  stomachic  tonic,  and 
may  be  given  for  the  purpose  in  an  in- 
fusion (hop-tea),  using  a  half-ounce  to 
the  pint  of  boiling  water,  of  which  al- 
most unlimited  quantities  may  be  given. 
It  is  useful  in  simple  flatulent  colic; 
atonic  dyspepsias,  and  mild  diarrhoea. 
The  infusion  given  in  doses  of  1/2  to  1 
wineglassful,  before  meals,  increases  the 
appetite  and  aids  digestion.  The  in- 
fusion diluted  with  twice  its  bulk  of 
water  is  useful  as  a  summer  drink  and 
to  quench  the  thirst  in  mild  febrile 
affections. 

Sedative. — The  tincture  of  hops  and 
the  oleoresin  of  lupulin  are  of  great 
value  in  mild  cases  of  delirium  tremens, 
as  they  act  both  as  a  stomachic  tonic  and 
as  a  cerebral  sedative.  Bartholow  sug- 
gests as  a  substitute  for  alcoholic  stimu- 
lants:— 

Fluid  extract  of  lupulin, 
Tincture  of  capsicum,  of  each.  1 
ounce. 

Of  this  mixture  1  or  2  teaspoon fuls 
are  given  as  necessary.  The  condition 
known  as  "horrors,"  or  the  wakefulness 
and  excitement  of  the  prodromal  stage 
of  delirium  tremens,  may  often  be  re- 


MACE. 

moved  by  the  free  use  of  this  combina- 
tion. Infusion  of  hops  is  also  useful 
during  recovery  from  a  debauch  or  dur- 
ing treatment  for  alcoholism  or  the 
opium  habit. 

G  E  N I T  O-U  RINARY  IRRITATION.  In 

all  kinds  of  irritation  of  the  genito- 
urinary tract  it  is  useful.  Irritable  blad- 
der, priapism,  chordee,  seminal  emis- 
sions, incontinence  of  urine,  and  sexual 
erethism  in  its  varied  phases  yield  to 
lupulin,  given  in  doses  of  5  to  10  grains 
in  syrup  or  jelly  (larger  doses  of  lupulin 
may  cause  colic  and  constipation). 

External  Uses.  —  Hops  are  useful 
externally  as  a  sedative  and  soporific. 
For  the  relief  of  pain,  the  hop-bag — 
dipped  into  hot  water,  applied  locally, 
and  covered  with  rubber-cloth  or  oiled 
muslin — is  a  useful  and  efficient  remedy. 
The  hop-poultice  may  be  made  by  mix- 


MAGNESIA.  457 

ing  hops  in  with  the  flaxseed-poultice 
when  ready  to  spread  upon  the  cloth. 
Hops  may  be  inclosed  in  a  flannel  bag 
and  then  dipped  into  hot  whisky  and 
applied  locally  for  pain,  as  in  toothache 
or  earache;  the  hops  seem  to  add  a  sooth- 
ing effect  to  the  warmth  and  moisture. 

Lefferts  advises  the  use  of  inhalations 
of  the  vapor  of  hops  in  diseases  of  the 
throat  and  chest.  He  directs  that  20 
grains  of  dried  carbonate  of  soda  be  dis- 
solved in  a  pint  of  warm  water  (140° 
F.),  1  drachm  of  extract  (inspissated 
fluid  extract)  of  hops  be  added,  and  the 
vapor  inhaled. 

The  hop-pillow  has  been  used  in  in- 
somnia especially  when  associated  with 
neurasthenia. 

LUPUS.    See  Tuberculoses. 

LYMPHADENITIS.    See  Adenitis. 


MACE.— Mace  (Macis,  U.  S.  P.)  is  the 
arillode  of  the  seed  of  Myristica  fragrans 
(nutmeg),  which  is  indigenous  to  the 
East  Indies.  Its  active  principle  is  a  ! 
volatile  oil,  which  closely  resembles  oil 
of  nutmeg.  Mace  and  its  volatile  oil  are 
used  principally  for  flavoring  purposes, 
but  occasionally  as  carminatives.  Mace 
is  given  in  doses  from  1/2  to  1  grain. 
The  oil  (non-official)  may  be  given  in 
doses  of  1  to  3  drops  on  sugar. 

Physiological  Action.  —  The  volatile 
oil,  as  shown  by  the  experiments  of  H.  C.  ; 
Wood  and  Cadeac  and  Meunier,  causes, 
when  injected  into  the  veins  of  lower 
animals,  marked  intoxication,  character- 
ized by  tremors,  loss  of  co-ordination, 
and  gradually-increasing  frequency  of 
respiratory  motions.  In  excessive  doses 
there  is  narcosis;   loss  of  reflexes  and 


death  from  paralysis  of  the  respiratory 
centres  follows. 

Therapeutics. — Mace  is  an  aromatic 
stomachic  and  tonic,  and  in  large  doses  a 
powerful  narcotic.  The  oil  is  sometimes 
employed  externally,  as  a  rubefacient  in 
paralysis  and  rheumatism.  Poisonous 
doses  cause  a  sensation  of  great  thirst,  a 
feeling  of  tightness  in  the  chest,  and  in- 
duce vomiting.  Coffee  and  stimulants 
are  indicated  when  poisonous  doses  have 
been  taken. 

MAGNESIA. — Magnesium  is  a  metal, 
light  and  having  the  appearance  of  sil- 
ver, which,  when  rolled  in  thin  plates 
or  ribbons,  can  be  ignited,  and  will  burn 
with  a  brilliant,  white  flame,  giving  olT  a 
dense  white  smoke,  which  is  the  oxide, 
or  magnesia.    The  metal  is  not  used  in 


458 


MAGNESIA.    PHYSIOLOGICAL  ACTION. 


medicine.  The  oxide,  magnesia,  and 
some  of  its  salts,  carbonate,  citrate,  and 
sulphate  are  official. 

Magnesia  (light  or  calcined  magnesia) 
occurs  as  a  very  light,  white  powder, 
having  a  slightly  alkaline  taste.  It  is 
soluble  in  dilute  acids  and  in  carbonic- 
acid  water.  It  unites  with  water  form- 
ing a  hydrate.    Dose,  5  to  60  grains. 

Magnesia  ponderosa  (heavy  magnesia) 
occurs  as  a  dense,  white,  very  fine  pow- 
der. It  does  not  form  a  hydrate  as  read- 
ily as  the  light  oxide.  Dose,  5  to  60 
grains. 

Magnesii  carbonas,  or  light  carbonate 
of  magnesium,  is  prepared  by  precipita- 
tion, and  occurs  as  perfectly  white,  light 
cubes,  of  a  slightly-earthy  taste  and  very 
friable,  and  is  soluble  in  3000  parts  of 
water,  and  more  freely  in  carbonic-acid 
water.    Dose,  1  to  3  drachms. 

Magnesii  citras  effervescens,  or  granu- 
lated effervescing  citrate  of  magnesium, 
is  a  mixture  of  magnesium  citrate,  a  so- 
dium bicarbonate,  citric  acid,  and  sugar. 
It  occurs  as  a  deliquescent,  coarsely- 
granular,  white  powder,  without  odor, 
having  a  mildly-acidulated,  pleasant 
taste,  and  being  soluble  in  2  parts  of 
water.    Dose,  1/i  to  1  ounce. 

Liquor  magnesii  citratis  is  made  from 
magnesium  carbonate,  citric  acid,  syrup 
of  citric  acid,  and  water;  before  dis- 
pensing, potassium  bicarbonate  is  added, 
the  bottle  securely  corked,  and  then  well 
shaken.    Dose,  1/4  to  1  ounce. 

Magnesii  sulphas  (Epsom  or  bitter  salt 
or  salts)  occurs  in  small,  colorless  prisms 
or  needles,  without  odor,  but  having  a 
bitter,  saline  taste;  it  is  soluble  in  1  1/2 
parts  of  water.   Dose,  1/2  to  1  1/2  ounces. 

Magnesia  and  magnesium  carbonate 
are  alkaline;  magnesium  citrate  and  sul- 
phate are  neutral  salts. 

Perri  oxidum  hydrastum  cum  mag- 
nesia.   Sec  Iron. 


Pulvis  rhei  compositus.     See  Ehu- 

BARB. 

Infusum  senna?  compositum.  See 
Senna. 

Physiological  Action.  —  Administered 
alone,  magnesium  acts  very  slowly  as  a 
purgative,  but,  contrary  to  the  effects  ob- 
tained from  sulphate  of  sodium,  the 
purgative  effect  seems  to  increase  when 
the  same  dose  is  repeated  several  days  in 
succession.  Again,  while  the  former 
agent  gives  rise  to  no  notable  phenomena 
in  the  intestinal  tract,  magnesium,  ac- 
cording to  Trousseau  and  Pidoux,  may 
induce  an  active  inflammatory  process, 
thus  giving  rise  to  the  bloody  atonic 
evacuations  and  the  tenesmus  occasion- 
ally noticed.  Armaud  Moreau  observed 
that  when  a  15-  to  20-per-cent.  solution 
of  magnesium  was  inclosed  in  an  intes- 
tinal loop,  between  two  ligatures,  very 
active  and  localized  secretion  followed, 
the  result  of  osmosis.  The  purgative  ac- 
tion is  also  sustained,  however,  by  the 
magnesium  absorbed  in  the  blood, 
though  the  salt  thus  absorbed  is  mainly 
eliminated  by  the  kidneys.  It  can  be 
found  in  the  urine  twent}'-four  or  thirty- 
six  hours  after  the  purgative  effects  are 
produced. 

To  increase  the  rapidity  of  its  action, 
citric  acid  is  usually  added  to  magne- 
sium. A  bicarbonate  is  thereby  obtained 
which  is  actively  cathartic. 

Saline  purgatives  have  the  power  of  ex- 
citing more  or  less  the  glands  of  the  in- 
testines and  of  causing  them  to  pour 
forth  their  secretions  abundantly.  In 
moderate  doses  magnesium  sulphate  ac- 
complishes this  without  appreciably 
stimulating  the  peristaltic  action.  Thia 
being  the  case,  a  part  of  the  fluid  poured 
out  may  be  reabsorbed  and  carry  with  it 
into  the  blood  a  quantity  of  the  salt,  and 
also  cause  the  contents  of  the  bowel  to 
lose  their  fluid  or  semisolid  consistency. 
This  seems  to  explain  its  action  When 
given  hypodermically  and  also  to  ex- 


MAGNESIA.  THERAPEUTICS. 


459 


plain  constipation  after  the  drug  has  been 
given  per  rectum.  In  cases  treated  by  the 
drug  2  or  3  grains  of  neutral  magnesium 
sulphate  injected  into  the  deep  muscular 
layers  of  the  nates  in  men,  or  into  the 
calf  of  the  leg  in  women,  were  successful 
in  70  per  cent,  of  the  cases;  20  per  cent, 
required  more  than  one  injection,  and  in 
10  per  cent,  the  bowels  failed  to  act.  In 
nearly  all  cases  the  bowels  moved  within 
ten  hours  after  injection.  James  Wood 
(Ther.  Gaz.,  Jan.  15,  '95). 

The  preparations  of  magnesium  are 
not  free  from  toxic  properties  when 
taken  in  large  doses. 

Case  of  a  woman,  aged  30  years,  in  her 
usual  health,  who  on  retiring  at  night, 
took  an  ounce  of  Epsom  salts.  On  the 
following  morning  she  was  found,  in  her 
room,  dead.  A  careful  post-mortem  and 
chemical  analysis  yielded  no  evidence  of 
any  other  cause  of  death.  A.  P.  Luff 
(Brit.  Med.  Jour.,  Sept.  5,  '91). 

Case  of  a  woman,  about  35  years  old, 
who  took  at  a  single  dose  4  ounces  of  Ep- 
som salts,  dissolved  in  hot  water.  An 
hour  later  she  had  burning  pains  in  the 
stomach  and  bowels;  difficult  respira- 
tion, attended  by  a  choking  feeling;  and 
a  peculiar  weakness  in  the  arms  and  legs. 
There  was  no  vomiting  or  purging. 
Presently  extreme  collapse  occurred;  the 
pupils  were  dilated;  there  was  slight 
twitching  of  the  facial  muscles;  paralysis 
of  the  limbs  was  observed.  The  patient 
quickly  became  comatose,  and  death  fol- 
lowed in  an  hour  and  fifteen  minutes 
after  the  dose  was  swallowed.  There  was 
no  autopsy.   Lang  (Lancet,  Nov.  7,  '91). 

Literature  of  '96-'97-'98. 

Case  in  which  patient  took  1  ounce  of 
Epsom  salts.  Only  three  slight  motions 
resulted,  and  towards  evening  he  began 
to  feel  very  ill,  and  remained  so  through 
the  night.  The  following  day  he  was 
too  ill  to  do  anything.  His  illness  con- 
tinued, and  he  vomited  frequently  during 
the  day.  At  C  p.m.  he  was  found  lying 
on  the  bed  in  an  attitude  of  flexion,  per- 
fectly indifferent  to  his  surroundings,  but 
answering  questions  intelligently  when 
smartly  roused.  The  face  and  hands  were 
deeply  cyanosed,  the  lips,  eyelids,  alse 


nasi,  and  auricles  being  of  a  dark-purple 
color,  while  the  conjunctivae  were  in- 
tensely congested  and  the  pupils  dilated 
and  unequal.  The  covered  parts  of  the 
body  presented  a  roseolous  rash,  and 
there  was  a  zone  of  herpes  zoster  in 
the  left  submammary  region  extending 
around  to  the  back.  At  this  time  the 
boy  had  several  attacks  of  tetanic  spasms, 
affecting  the  right  side  of  the  face  and 
passing  down  the  right  arm,  together 
with  pronation  of  the  hand.  The  tongue 
and  teeth  were  covered  with  sordes,  the 
stomach  was  enormously  dilated,  and 
urine  was  dribbling  away.  The  right 
radial  pulse  was  absent  and  the  left 
hardly  perceptible;  the  heart-beats  were 
feeble  and  could  not  be  counted.  The 
extremities  were  cold;  the  axillary  tem- 
perature was  105°. 

He  was  given  a  dose  of  hot  brandy  and 
water,  well-covered  with  blankets  and 
packed  with  hot-water  bottles.  This  was 
followed  by  a  draught  containing  car- 
bonate of  ammonia,  spirit  of  ether,  and 
tincture  of  strophanthus.  During  the 
night  he  had  frequent  vomitings  of  a 
greenish  fluid.  The  next  morning  the 
cyanosis  was  less  marked,  the  radial 
pulses  were  perceptible,  and  he  was  bet- 
ter and  more  conscious  of  his  surround- 
ings. 

As  his  bladder  was  greatly  distended, 
he  was  catheterized  and  about  40  ounces 
of  urine  drawn  off.  By  the  end  of  the 
week  he  was  practically  well.  J.  H. 
Neale  (Lancet,  Aug.  15,  '96). 

Therapeutics. — Antacid. — Magnesia, 
magnesia  ponderosa,  and  magnesium  car- 
bonate are  used  as  antacids.  Of  these, 
magnesia  ponderosa  would  seem  to  be, 
perhaps,  the  best.  Magnesia  has  the  dis- 
advantage of  being  bulky  in  sufficient 
dose,  and  magnesium  carbonate  is  apt  to 
give  rise  to  flatulence  on  account  of  the 
carbonic-acid  gas  given  off  when  it  is 
subjected  to  the  disintegrating  action  of 
the  acid  of  the  gastric  juice.  The  latter 
objection,  however,  does  not  always  hold, 
since  the  stimulating  action  of  the  car- 
bonic-acid gas  upon  the  mucous  mem- 
brane of  the  stomach  is  often  beneficial, 


460 


MAGNESIA.  THERAPEUTICS. 


acting  as  a  sedative  and  anodyne  in  the 
treatment  of  indigestion,  sick  headache, 
and  pyrosis.  In  diarrhoea  from  indiges- 
tion, with  acid  stools,  magnesia  combined 
with  rhubarb  yields  very  satisfactory  re- 
sults. 

Magnesia  is  free  from  taste,  is  non- 
irritating  and.  antacid,  and  is,  therefore, 
a  very  desirable  remedy  to  administer  to 
children.  The  carbonate  combined  with 
carminatives  is  especially  useful  in  the 
flatulent  colic  and  diarrhoea  of  young 
infants.    Demers's  formula  is: — 

I£  Carbonate  of  magnesia,  1/2  drachm. 

Tincture  of  asafcetida?,  40  drops. 

Laudanum,  20  drops. 

Sugar,  1  drachm. 

Distilled  water,  1  ounce. — M. 
The  dose  is  1/3  to  1  teaspoonful,  ac- 
cording to  age. 

Dalby's  formula  is  similar: — 

Ty  Carbonate  of  magnesia,  40  grains. 

Oil  of  peppermint,  1  drop. 

Oil  of  nutmeg,  2  drops. 

Oil  of  anise,  3  drops. 

Tincture  of  castor,  30  drops. 

Tincture  of  asafcetidse,  15  drops. 

Tincture  of  the  oil  of  pennyroyal, 
15  drops. 

Compound  tincture  of  cardamom., 
30  drops. 

Peppermint-water,  2  ounces. — M. 
The  dose  is  a  teaspoonful  as  required. 

Gout  and  lithiasis  are  benefited  by  the 
antacid  magnesia  preparations,  but  the 
potash-  or  lithia-  salts  are  more  efficient. 

Antidote  to  Poisons. — The  antacid 
properties  of  magnesia  make  it  valuable 
as  a  antidote  in  cases  of  poisoning  by  the 
strong  mineral  or  vegetable  acids.  It 
neutralizes  the  acids  and  acts  as  a  me- 
chanical protective  to  the  tissues  against 
the  corrosive  action  of  the  acid-poisons. 
Its  value  as  an  antidote  in  poisoning  by 


metallic  salts  depends  upon  the  fact  that 
it  precipitates  many  metals  from  their 
acid  of  combination,  and  thus  renders 
the  metal  less  soluble  and,  therefore,  less 
poisonous.  In  poisoning  by  arsenic, 
freshly-prepared  hydrate  of  magnesia  is 

|  an  antidote  of  no  mean  value,  but  is  not 
so  effective  as  the  official  hydrate  oxide 

I  of  iron  with  magnesia,  of  which  doses 
of  1  to  4  drachms  are  given. 

Purgative. — Magnesia  and  carbonate 
of  magnesia  are  often  used  as  purgatives 
in  children,  as  before  mentioned.  The 
neutral  salts,  the  citrate  and  sulphate, 
are  more  generally  used  for  this  purpose. 
Magnesia  and  the  carbonate  are  hardly 
suitable  for  continuous  administration, 
as,  being  insoluble,  they  may  accumulate 

1  in  the  intestines  and  form  concretions 

I  consisting  of  the  hydrate  of  magnesia. 
The  citrate  and  sulphate  of  magnesia 
cause  little,  if  any,  irritation,  and  are  on 

I  that  account  valuable  as  laxatives  in  en- 
teritis and  peritonitis.  In  febrile  affec- 
tions, given  in  small  doses,  they  exert  a 
refrigerant  and  slight  diuretic  action. 

I  Combined  with  iron,  they  are  useful  in 

I  constipation  associated  with  atonic  con- 
ditions.  In  anaemia  and  chlorosis,  which 

I  Clarke  attributes  to  fsecal  intoxication, 
the  "mistuTa  ferro-salina"  is  a  useful 
tonic  laxative. 

1}  Sulphate  of  magnesia,  1  ounce. 
Cream  of  tartar,  1  drachm. 
Dried  sulphate  of  iron,  10  grains. 
Water,  2  pints. — M. 
Of  this  a  wineglassful  should  be  taken 
!  a  half-hour  before  breakfast  each  morn- 
ing. 

The  constipation  of  lead  poisoning  is 
relieved  best  by  magnesium  sulphate  as 
follows: — 

I>  Magnesium  sulphate,  2  drachms. 
Morphine  sulphate,  1  grain. 
Peppermint-water,  3  ounces. 


MALARIAL  FEVERS. 


461 


Mix  and  give  a  tablespoonful  every  two  I 
hours  in  lead  colic. 

The  purgative  mineral  waters  (Fried- 
richshall,  Pullna,  Sedlitz,  and  Hunyadi 
waters)  owe  their  purgative  action  prin- 
cipally to  the  presence  of  magnesium 
sulphate. 

Serous  Effusions.  —  Magnesium 
sulphate  given  in  doses  of  1  or  2  ounces 
daily,  in  as  little  water  as  will  dissolve 
the  salt,  will  yield  good  results  in  serous 
effusions  (pleural,  peritoneal,  etc.),  espe- 
cially if  the  amount  of  fluids  ingested  be 
restricted.  It  may  be  given  by  enema  if 
preferred,  as  proposed  by  Watkins: — 

3^  Magnesium  sulphate,  2  ounces. 
Glycerin,  1  ounce. 
Water,  4  ounces. 

(Edema  and  Anasarca.  —  (Edema 
and  anasarca  are  relieved  in  a  similar 
manner  by  magnesium  sulphate.  It  re- 
lieves the  congestion  of  the  kidneys  in 
general  anasarca.  It  is  also  of  value  in 
oedema  of  the  lungs  and  brain,  in 
Bright's  disease,  and  ascites.  In  uraemia 
associated  with  constipation,  magnesium 
sulphate  is  a  valuable  remedy. 

Diarrhcea  and  Dysentery. — Diar- 
rhoea from  faecal  impaction  is  best  re- 
lieved by  small  doses  of  magnesium  sul- 
phate every  hour.  It  is  also  useful  in 
dysentery  combined  with  aromatic  sul- 
phuric acid  and  laudanum.  In  acute 
dysentery  it  will  often  remove  the  fever, 
the  blood  and  mucus  from  the  stools, 
and  the  tenesmus.  Leahy  advises  the 
use  of  the  following:  Saturate  7  fluid- 
ounces  of  water  with  a  sufficient  quan- 
tity of  magnesium  sulphate,  and  add  1 
ounce  of  diluted  sulphuric  acid.  Of  this 
iiivc  a  tablespoonful  every  hour  or  two 
in  a  wineglassful  of  water  until  it  op- 
erates. Morphine  may  be  added,  or 
Btarch  cncmata  with  laudanum  may  be 
used. 


In  summer  diarrhoea  magnesium  sul- 
phate is  strongly  advocated.  From  1 
teaspoonful  to  a  tablespoonful  of  the  salt, 
according  to  the  age,  moistened  suf- 
ficiently to  be  swallowed,  may  be  given 
daily  until  the  discharges  become  yellow. 
Koplik  (Jour.  Amer.  Med.  Assoc.,  Oct.  12, 
'95). 

Rectal  Disorders. — Magnesium  sul- 
phate is  an  agent  of  great  value  in  rectal 
disorders,  as  it  liquefies  the  faecal  pas- 
sages and  renders  them  less  irritating. 
In  cancer  or  stricture  of  the  rectum  and 
fissure  of  the  anus  this  is  very  desirable. 
This  and  other  salines  will  act  painlessly 
upon  the  bowels  of  a  patient  fully  under 
the  influence  of  opium,  which  renders 
them  especially  useful  in  atony  of  the 
rectum. 

The  unpleasant  taste  of  magnesium 
sulphate  may  be  disguised  by  a  small 
amount  of  the  fluid  extract  of  licorice 
or  by  boiling  it  with  or  giving  it  in 
coffee.  For  general  use  4  ounces  of 
magnesium  sulphate  may  be  dissolved  in 
4  ounces  of  lemon  or  other  syrup,  and 
enough  water  added  to  make  one  pint. 
Of  this  the  dose  is  a  wineglassful  or  two. 

External  Uses.  —  Magnesium  and 
the  carbonate  are  used  as  a  toilet  powder, 
to  dry  the  skin,  to  prevent  chapping  and 
excoriation  in  intertrigo,  and  to  relieve 
the  irritation  due  to  sunburn  and  that 
left  after  shaving.  This  is  applied  also 
as  a  cosmetic  to  relieve  the  shining  ap- 
pearance and  gloss  of  the  facial  integu- 
ment, the  cubes  of  magnesium  carbonate 
being  generally  preferred  for  this  pur- 
pose. 

C.  Sumner  Witherstine, 

Philadelphia. 

MALARIAL  FEVERS. 
Definition. — Under  the  name  malaria 
is  included  that  group  of  diseases  due  to 
I  infection  with  the  animal  parasite  de- 


462 


MALARIAL  FEVERS.    THE  MALARIAL  PARASITE. 


scribed  by  Laveran  and  now  known  as  the 
haematozoon  malaria1,  or,  less  appropri- 
ately, plasmodium  malariaa. 

The  term  malaria  was  originally  ap- 
plied to  these  diseases  to  designate  the 
conditions  then  most  evident  in  their 
production,  having  its  derivation  from 
the  Italian  mal'aria,  the  English  equiv- 
alent of  which  is  "bad  air."  While  this 
is  in  no  wise  descriptive  of  the  disease, 
either  clinically  or  pathologically,  the 
name  has  obtained  such  wide  usage  that 
its  continued  employment  is  fully  justi- 
fied. 

The  protozoon  discovered  by  Laveran 
is  to  be  regarded  as  always  present  in  ma- 
laria, and  in  accordance  with  the  variety, 
or  species,  of  the  parasite  present  its 
effects  are  manifested  as  quartan  and  ter- 
tian fever,  which  are  the  regularly  inter- 
mittent forms  of  the  disease,  and  as 
aestivo-autumnal  fever,  which  includes 
the  irregularly  intermittent  and  remit- 
tent forms,  as  well  as  the  pernicious 
varieties  and  chronic  malarial  cachexia. 

Synonyms. — Malarial  fever  is  known 
by  many  synonyms,  which  are  frequently 
derived  from  the  localities  in  which  it 
prevails;  as,  Eoman  fever,  Chagres  fever, 
Panama  fever,  African  fever,  jungle 
fever,  lake  fever,  coast  fever;  also,  palu- 
dism,  paludal  fever,  autumnal  fever, 
marsh  fever,  swamp  fever,  marsh  miasm 
or  miasmatic  fever,  fever  and  ague,  and 
chills  and  fever.  In  accordance  with  the 
intensity  of  particular  symptoms  the  dis- 
ease may  be  known  as  intermittent  fever, 
remittent  fever,  congestive  fever,  black- 
water  fever,  hemorrhagic  malarial  fever, 
and  bilious  remittent  fever. 

The  Malarial  Parasite  and  Mechanism 
of  Infection. 

The  malarial  parasite  is  a  unicellular 
organism  belonging  to  the  das-  of  proto- 
zoa, and  first  discovered  and  described  by 
the  French  military  surgeon  Laveran  in 


|  1880.  Since  the  publication  of  Laveran's 
discovery  his  observations  have  been  con- 
firmed and  enlarged  upon  by  many  ob- 
servers in  all  parts  of  the  world,  and, 

|  while  there  is  still  but  little  known  of 
the  life  of  the  organism  outside  the 
human  body,  its  causative  relation  to 
malarial  fever  has  been  conclusively 
demonstrated.  Laveran's  work  was  first 
confirmed  by  Richard,  in  Algiers,  in 
1882,  and  later  by  Marchiafava  and  Celli, 
the  results  of  whose  observations  were 
derived  from  the  study  of  dried  malarial 
blood  subjected  to  staining.  In  1885-86 
our  knowledge  of  the  subject  was  greatly 
advanced  by  G-olgi,  who  proved  the  rela- 
tion existing  between  the  different  stages 
of  the  malarial  paroxysm  and  the  cycle 
of  development  of  the  parasite.  The 
same  observer  first  recognized  two  special 
varieties  of  the  parasite  as  belonging  each 
to  quartan  and  tertian  fever,  while  still 
later,  in  1889,  Marchiafava  and  Celli 
recognized  particular  forms  associated 
wdth  sestivo-autumnal  fever.  In  America 
the  investigations  of  Councilman.  Stern- 
berg, Osier,  Dock,  and  Thayer  and  Hew- 
etson  have  added  much  to  our  knowl- 
edge of  the  subject. 

It  will  thus  be  seen  that  at  least  three 
varieties  of  malarial  parasites  are  to  be 
considered,  each  of  which  passes  through 
a  cycle  of  development  which  in  its  gen- 
eral characteristics  is  common  to  all.  In 
accordance  with  the  variety  of  parasite 
the  cycle  of  development  varies  in  dura- 
tion from  twenty-four  to  seventy-two 
hours.  Development  begins  in  the  form 
of  small,  hyaline  bodies  within  the  red 
blood-cells,  possessing  the  power  of  amoe- 
boid movement,  and  without  color.  In- 
crease in  the  size  of  these  bodies  takes 
place  and  coincident  lv  then1  is  to  be  ob- 
served within  them,  near  the  periphery 

I  of  the  parasite,  a  collection  of  pigment- 

I  granules.     These  granules  increase  in 


PLATE  I. 


V6 


10 


16 


f3 


'--if* 


20 


2f 


22 


The  Malarial  Parasite  ( Mannaberq.] 

"Die  Malanaerkrankunqen"  A  Holder. Publisher, Vienna 


urn ii  MtYfiTJQDGE  at.  uiv  ma* 


MALARIAL  FEVERS.    THE  MALARIAL  PARASITE. 


463 


amount  with  the  further  development  of 
the  parasite,  and  are  frequently  observed 
to  be  in  active  motion. 

With  the  attainment  of  maturity  the 
parasite  gradually  becomes  quiescent, 
and  completely  or  only  partly  fills  the 
red  blood-cell,  as  the  description  may 
apply  to  one  or  the  other  variety  of  para- 
site. Changes  in  the  corpuscular  host  of 
the  parasite,  affecting  chiefly  its  shape 
and  color,  occur  coincidently  with  the 
various  stages  of  parasitic  development. 

The  parasite  having  reached  its  full  de- 
velopment, the  pigment-granules  within 
it  begin  to  clump,  usually  near  the  cen- 
tre, and  the  stage  of  segmentation  com- 
mences. When  completed,  the  process 
divides  the  parasite  into  a  number  of 
oval  bodies  or  spores,  while  the  corpus- 
cle which  has  acted  as  host  bursts 
and  the  subdivisions  of  the  parasite,  or 
spores,  are  set  free,  the  pigment-gran- 
ules remaining  behind  to  float  free  in  the 
blood-serum  or  to  be  taken  care  of  by 
the  process  of  phagocytosis.  The  spores 
thus  set  free  very  soon  enter  fresh  cor- 
puscles and  there  begin  the  cycle  of  de- 
velopment anew. 

In  accordance  with  the  observations 
of  Golgi  and  of  March iafava  and  Celli, 
confirmed  by  many  others,  three  varie- 
ties of  parasites  may  be  differentiated: 
(1)  the  parasite  of  quartan  fever,  (2)  the 
parasite  of  tertian  fever,  and  (3)  the 
parasite  of  aestivo-autumnal  fever. 

Colored  Plate  I. — Parasites  of  the  First 
Group. — Fig.  A.  1-22.  Phases  of  development 
of  the  quartan  parasite.  23.  Rare  form  of 
sporulation.  Fig.  B.  Plan  of  the  sporulation 
of  Hi!'  quartan  parasite  according  to  Golgi. 
Fig.  C.  Melaniferous  leucocytes.  Fig.  D.  Vacu- 
oles of  red  corpuscles  undergoing  changes  in 
shape. 

1.  The  quartan  parasite  attains  its 
full  development  in  seventy-two  hours 
and  shows  more  regularity  in  its  evolu- 


tion than  any  other  variety.  Unlike  the 
tertian  and  aastivo-autumnal  varieties,  it 
completes  its  development,  not  in  the 
viscera  and  bone-marrow,  but  entirely  in 
the  circulating  blood. 

The  young  parasite  is  small,  about  one- 
fifth  to  one-fourth  the  size  of  the  red 
blood-cell,  and  exhibits  amoeboid  move- 
ments that  are  sluggish  when  compared 
with  the  movements  of  the  tertian  para- 
site. As  the  parasite  grows,  occupying 
eventually  a  little  more  than  one-half  to 
two-thirds  of  the  corpuscle,  pigment- 
granules  appear  within  it.  This  pigment 
is  coarse  and  dark,  as  compared  with  the 
pigment  within  the  tertian  parasite,  and 
does  not  present  the  active  motion  to  be 
observed  in  the  pigment-granules  of  the 
latter  variety.  The  corpuscle  surround- 
ing the  parasite  often  becomes  deeper  in 
color  and  frequently  assumes  a  coppery 
hue,  while  at  the  same  time  it  may  be- 
come a  little  smaller  and  somewhat  shriv- 
eled. In  the  full  development  of  the 
parasite  the  corpuscle  is  frequently  ob- 
served as  a  thin  layer  surrounding  the 
parasite,  which  now  presents  the  evi- 
dences of  segmentation  and  the  massing 
of  pigment-granules.  This,  however, 
does  not  always  take  place  in  the  centre 
of  the  parasite,  but  frequently  toward  the 
peripher}^,  and  not  uncommonly  shows  a 
striated  arrangement.  This  distribution 
of  the  pigment  in  striae  extending  from 
the  periphery  to  the  centre  divides  the 
organism  into  segments,  from  six  to 
twelve  in  number,  in  which  can  be  ob- 
served the  spores,  and  thus  produces  the 
rosette  forms  described  by  Golgi.  The 
completion  of  segmentation  results  in 
setting  free  the  spores  which,  as  young 
hyaline  bodies,  invade  other  corpuscles 
and  begin  a  new  cycle  of  existence. 

At  times,  infection  by  more  than  one 
group  of  quartan  parasites  occurs,  result- 
ing, if  the  infection  be  with  two  groups, 


464 


MALARIAL  FEVERS.    THE  MALARIAL  PARASITE. 


in  double  quartan,  if  with  three  groups 
in  triple  quartan  fever. 

Although,  as  stated,  the  quartan  para- 
site is  more  regular  in  its  development 
than  the  other  varieties,  deviations  in 
certain  instances  from  the  description 
just  given  may  be  noted.  The  mature 
parasite,  instead  of  sporulating,  may,  in 
the  quartan  variety  as  well  as  any  variety, 
develop  into  the  flagellate  form;  while 
certain  other  parasites,  failing  of  sporula- 
tion,  after  escaping  from  the  corpuscles 
become  much  swelled  and  present  irregu- 
larities of  outline,  eventually  breaking 
up  into  a  number  of  irregular  forms,  or 
becoming  vacuolated  in  their  entirety. 

Colored  Plate  II. — Parasites  of  the  First 
Group. — Fig.  A.  1-22.  Phases  of  development 
of  the  ordinary  tertian  parasite  (17  and  18, 
according  to  Thayer  and  Hewetson).  23-29. 
Hydropic,  degenerated,  disintegrated  bodies. 
Fig.  B.  Plan  of  sporulation  of  the  tertian  para- 
site according  to  Golgi. 

2.  The  tertian  parasite  requires  forty- 
eight  hours  to  complete  its  cycle  of  de- 
velopment. Although  this  parasite  is  to 
be  found  in  the  circulating  blood  during 
certain  stages  of  its  development,  sporu- 
lation takes  place  chiefly  in  the  spleen 
and  bone-marrow,  and  in  this  particular 
differs  from  the  quartan  organism.  The 
young  tertian  parasite  appears  in  the  red 
blood-corpuscles  as  a  small,  pale  body, 
1  to  2  microns  in  diameter,  possessing  ac- 
tive amoeboid  motion.  Not  only  are  the 
movements  more  active  than  with  the 
quartan  parasite,  but  from  the  periphery 
of  the  tertian  parasite  long,  branching 
prolongations,  or  pseudopodia,  are  sent 
out  aud  which  very  soon  are  again  with- 
drawn, to  be  followed  by  another  change 
in  the  shape  of  the  organism.  This 
stage  of  development  may  last  for 
twenty-four  hours,  and  then  the  para- 
site begins  to  collect  pigment-granules 
and  rods,  which  arc  finer  and  of  lighter 


color  than  in  the  quartan  parasite,  and 
tend  to.  collect  particularly  around  the 
periphery  of  the  organism.  The  move- 
ment of  the  pigment-granules  is  very 
active.  As  the  parasite  develops,  the  ac- 
cumulation of  pigment  increases  and  the 
amoeboid  movements  lessen.  Neverthe- 
less these  movements  do  not  cease  alto- 
gether, for  even  during  the  period  of  the 
paroxysm  marked  by  apyrexia  pigmented 
parasites  may  be  observed  to  undergo 
strange  alterations  in  form  by  the  send- 
ing out  of  pseudopodia,  although  by  this 
time  more  than  half  of  the  red  blood- 
corpuscle  serving  as  host  may  have  been 
occupied.  (Mannaberg.)  The  red  blood- 
corpuscles  infected  with  the  tertian  para- 
site undergo  decided  changes,  becoming 
distinctly  swelled,  and,  when  compared 
with  the  uninfected  corpuscles,  are  ob- 
served to  be  much  paler  than  normal. 
At  times,  however,  the  red  blood-corpus- 
cles may  not  increase  in  size,  but  may 
actually  shrink  and  present  a  brassy  or 
greenish  tint. 

After  the  lapse  of  about  forty-eight 
hours  sporulation  occurs,  having  been 
preceded  by  the  complete  quiescence  of 
the  parasite  and  the  aggregation  of  the 
pigment-granules  into  a  mass  near  its 
centre.  Just  prior  to  segmentation  the 
parasite  attains  about  the  size  of  the 
normal  red  blood-corpuscle,  while  the 
swelled  corpuscle  containing  it  becomes 
pale  in  color. 

Segmentation  occurs  by  the  splitting 
up  of  the  parasite  into  15  or  20  divisions, 
or  segments,  which  are  not  arranged  with 
the  regularity  characterizing  the  quar- 
tan parasite.  The  larger  number  of 
spores  contrasted  with  the  smaller  num- 
ber resulting  from  segmentation  of  the 
quartan  parasite  constitutes  an  impor- 
tant factor  in  the  differentiation  of  the 
two  varieties  of  parasites.  The  spores  of 
the  tertian  parasite  are  round  and  smaller 


PLATE  II 


0 

PS 


72 


13 


Pi 


18 


19 


22 


23 


2't 


27 


ZH 


29 


30 


The  Malarial  Parasite  (  Mannaberq.) 

"Die  Malanaerkrankungen'   A. Hbl d er. Publisher. Vienna. 


MALARIAL  FEVERS.    THE  MALARIAL  PARASITE. 


465 


than  those  of  the  quartan  parasite,  and 
a  refractive  dotlet,  the  nucleolus,  which 
is  less  defined  than  in  the  quartan  spores, 
can  usually  be  observed. 

The  spores  having  been  set  free,  fresh 
blood-corpuscles  are  entered,  and  as 
young  parasites  the  cycle  of  development 
is  again  gone  through. 

The  act  of  sporulation  in  tertian,  as 
in  quartan,  infection  corresponds  with 
the  occurrence  of  the  paroxysm,  and  sev- 
eral hours  before  this  event  individual 
spores  may  be  detected  in  the  blood; 
they  are  to  be  found,  however,  in  great- 
est number  at  the  time  of  the  occurrence 
of  the  chill  or  during  the  beginning  of 
the  hot  stage  of  the  paroxysm. 

In  tertian  infection  not  all  the  para- 
sites pass  through  their  cycle  of  devel- 
opment in  a  typical  manner,  and  the  oc- 
currence of  flagellate  bodies  and  other 
degenerated  forms,  such  as  vacuolation, 
fragmentation,  etc.,  is  far  more  common 
than  in  the  quartan  variety. 

Infection  with  two  groups  of  tertian 
parasites  may  occur,  passing  through 
their  cycle  of  development  and  attaining 
maturity  upon  successive  days.  This  is 
of  more  common  occurrence  than  infec- 
tion with  a  single  group,  and  results  in 
the  production  of  a  fever  of  quotidian 
type. 

Anticipating  and  postponing  fevers  of 
the  tertian  variety  are  to  be  explained  by 
the  tendency  to  the  lack  of  regularity  in 
the  time  necessary  for  the  completion  of 
its  cycle  of  evolution;  thus,  the  time 
required  may  be  shorter  or  longer  than 
forty-eight  hours. 

3.  The  ceslivo-autumnal  parasite,  or 
Ilcematozoon  falciparum  of  Welch,  pre- 
sents peculiar  difficulties  in  study  for  the 
reason  that  its  cycle  of  development  is 
completed  mainly  within  the  internal 
organs.  Its  development  is  accompanied 
with  more  irregularity  than  that  which 


attends  the  other  varieties  of  parasites, 
and,  while  clinically  it  may  be  possible 
in  the  milder  instances  of  infection  to 
recognize  certain  types,  such  as  quotidian 
and  tertian,  the  type  is  so  confused  as 
to  render  its  analysis  almost  impossible. 
Recent  investigations  have  not  succeeded 
in  satisfactorily  proving  that  these  clin- 
ical variations  depend  upon  infection 
with  special  varieties  of  sestivo-autumnal 
parasites  completing  their  cycles  of  de- 
velopment upon  different  days,  and  the 
majority  of  observers  have  been  unable 
to  accept  the  division  of  the  gestivo-au- 
tumnal  parasite  into  a  quotidian  and 
tertian  variety  as  urged  by  Marchiafava 
and  Bignami. 

[In  this  connection  Thayer  and  Hewet- 
son  ("Amer.  System  of  Prac.  Med.," 
"Malaria,"  Welch  and  Thayer,  vol.  i,  p. 
39)  say:  "We  have  been  unable  to  trace 
a  constant  length  of  the  cycle  of  develop- 
ment, and  we  have  been  unable  further 
to  separate  two  or  more  types  of  the 
(sestivo-autumnal)  parasite  depending 
either  upon  the  length  of  the  cycle  of  de- 
velopment or  upon  any  other  morpholog- 
ical or  biological  differences.  We  believe 
that  the  length  of  the  cycle  varies  greatly 
in  different  cases,  lasting  usually  from 
twenty-four  hours,  or  even  a  little  less, 
to  forty-eight  hours  or  more.  After  the 
infection  is  five  days  or  a  week  old  cer- 
tain of  the  organisms,  instead  of  segment- 
ing, pursue  a  further  growth,  developing 
into  the  hyaline,  refractive,  ovoid,  and 
crescentic  bodies." 

The  contrary  view,  in  favor  of  the  di- 
vision, made  by  Marchiafava  and  Big- 
nami, is  held  by  Mannaberg  (Mannaberg, 
1899:  Nothnagel's  Spec.  Path.  u.  Ther., 
B.  2,  T.  2,  S.  68),  who  not  only  concurs 
in  the  division  of  the  sestivo-autumnal 
parasite  into  quotidian  and  tertian,  but 
further  subdivides  the  former  into  the 
pigmented  quotidian  parasite  and  the  un- 
pigmented  quotidian  parasite.  James  C. 
Wilson  and  Thomas  G.  Ashton.] 

The  aastivo-autumnal  parasite  possesses 
the  distinctive  characteristic  of  produc- 
ing crescent-shaped  bodies;  hence  Welch 


466 


MALARIAL  FEVERS.    THE  MALARIAL  PARASITE. 


lias  proposed  for  it  the  name  of  Hcema- 
tozoon  falciparum.  These  bodies  are  not 
usually  found  in  the  blood  until  a  case 
of  aBstivo-autumnal  fever  has  lasted  for 
a  week  or  more.  Their  development  is 
now  regarded  as  intracorpuscular,  and  in 
the  early  stages  of  their  evolution  they 
are  infrequently  met  with  in  the  cir- 
culating blood.  In  the  spleen  and  bone- 
marrow,  however,  particularly  the  latter, 
they  are  to  be  found  in  abundance. 
They  are  to  be  regarded  as  transformed 
from  the  intracorpuscular  spherical  or- 
ganisms, and  do  not  belong  to  the  cycle 
of  development  as  regularly  performed 
by  the  parasite.  Instead  of  being  cres- 
centic,  these  bodies  may  be  oval  or  fusi- 
form in  outline,  and,  of  whatever  form, 
are  always  pigmented. 

The  young  hyaline  body  of  the  sestivo- 
autumnal  parasite  is  the  smallest  of  the 
malarial  parasites,  and,  while  in  its 
earliest  stages  it  may  not  show  much 
activity,  in  the  course  of  its  development 
it  presents  marked  amoeboid  movements. 
It  is  to  be  observed  in  the  red  blood- 
corpuscle  during  or  shortly  after  the  par- 
oxysm, and  is  about  one-sixth  the  diam- 
eter of  its  host.  The  young  parasite  is 
distinct,  and  stands  out  in  contrast  to 
the  surrounding  structure  of  the  blood- 
corpuscle.  This  clear,  hyaline  ring  is 
usually  thicker  at  one  portion  of  its  cir- 
cumference, and  presents  one  or  more 
central  or  eccentric  shaded  dots,  through 
which  may  be  seen  the  color  of  the  red 
blood-corpuscle;  these  spots  are  sup- 
posed by  some  to  be  nuclei. 

With  the  development  of  the  parasite 
amoeboid  movements  become  active  and 
are  frequently  attended  with  the  throw- 
ing out  of  pseudopodia.  Pigment-gran- 
ules, at  first  very  fine  and  dark  brown  in 
color,  soon  begin  to  appear  toward  the 
periphery  of  the  parasite.  These  gran- 
ules later  increase  in  size  and  number; 


but  it  is  distinctive  of  the  sestivo-au- 
tumnal  parasite  that  they  are  fine  and 
relatively  few  in  number  and  possess  but 
little  motion.  With  the  approach  of  the 
paroxysm  the  parasite  becomes  quiescent 
and  the  pigment-granules  collect  at  or 
near  its  centre.  The  parasite  next  enters 
upon  the  stage  of  sporulation,  which  is 
characterized  by  much  greater  irregular- 
ity than  the  corresponding  stage  in  the 
evolution  of  the  other  varieties  of  mala- 
rial parasites.  The  number  of  spores  is 
variable  and  may  range  from  six  to 
twenty  or  more. 

The  corpuscle  enveloping  the  parasite 
may  not  show  any  change  in  appearance. 
Very  frequently,  however,  it  becomes 
shrunken  and  deformed  and  assumes  a 
brassy  color,  with  retraction  of  the  haemo- 
globin away  from  the  periphery  and  its 
distribution  around  the  parasite.  The 
fully-developed  parasite  in  the  preseg- 
menting  stage  is  smaller  than  the  quar- 
tan and  tertian  parasites  at  a  similar 
period  of  their  evolution,  and,  as  a  rule, 
is  not  more  than  one-fourth  or  one-third 
the  size  of  the  red  blood-corpuscle. 

Fever  of  a  quotidian  or  tertian  type 
may  result  from  aastivo-autumnal  infec- 
tion, and  this  association  is  to  be  ascribed 
to  variations  in  the  length  of  the  cycle  of 
development  of  the  parasite  rather  than 
to  infection  with  supposed  special  varie- 
ties. As  previously  observed,  however, 
Marchiafava  and  Bignami,  Mannaberg, 
and  others  subdivide  the  parasite  into 
quotidian  and  malignant  tertian  varie- 
ties, the  latter  in  contradistinction  to 
the  tertian  parasite  of  the  regular  variety 
described  by  Golgi.  Further,  not  all  of 
the  aastivo-autumnal  parasites  develop 
pigment-granules,  and  cases  occur  in 
which  no  pigmented  bodies  are  to  be  ob- 
served at  any  stage.  This  fact  has  led 
to  the  further  subdivision  of  the  so- 
called  quotidian  sestivo-autumna]  para- 


PLATE  III 


18 


20 


2k 


25 


26 


28 
# 


29 


3b 


* 


31 

4 


35 


36 


33 

© 


37 


38 


J.9 


h2 


43 


H9 


53 


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The  Malarial  Parasite  ( Mannaberq.) 

"Die  Malanaerkrankunqen"  A. Holder, Publisher  Vienna 


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The  Malarial  Parasite  (Mannaberq  i 

"Die  Malanaerkrankunqen"  A  Holder, Publisher. Vienna. 


MALARIAL  FEVERS. 


THE  MALARIAL  PARASITE. 


467 


site  into  pigmented  and  unpigmented 
forms  (Grassi  and  Feletti,  Mannaberg). 
The  following  description  is  given  by 
Mannaberg  as  distinctive  of  these  varie- 
ties:— 

Colored  Plate  III. — Parasites  of  the  Sec- 
ond Group. — Fig.  A.  1-G.  Pigmented  quotidian 
parasites.  Fig.  B.  7-13.  Unpigmented  quotid- 
ian parasites.  Fig.  C.  14-19.  Malignant  tertian 
parasites.  Fig.  D.  20.  Corpuscle  showing 
brassy  discoloration.  21-37.  Bodies  of  the 
crescentic  series.  24-26.  Coalescence  of  two 
amoeboid  parasites  (copulation).  27.  Syzygy. 
38-40.  Stained  crescentic  forms  (Romanow- 
sky's  method).  41-58.  Stained  parasites  of  the 
second  group.  49-57.  Showing  the  origin  of 
the  crescentic  bodies:  syzygies  (staining  with 
hematoxylin  after  picric-acid  fixation). 

The  pigmented  quotidian  parasite  com- 
pletes its  development  in  twenty-four 
hours;  it  begins  its  existence,  as  do  the 
other  forms,  as  a  very  small  body  without 
pigment.  It  is  pale  and  forms  but  little 
contrast  with  its  containing  blood-cor- 
puscle; so  that  it  would  readily  be  over- 
looked were  it  not  for  the  active  amce- 
moid  movements  it  possesses.  When  at 
rest,  however,  it  appears  as  a  small  dis- 
tinct ring  of  pale  color  and  with  a  red- 
dish centre,  the  latter  appearance  being 
probably  due  to  the  thinning  of  the  para- 
site at  that  point,  permitting  the  color 
of  the  red  blood-corpuscle  to  be  seen 
through  it.  The  young  parasite  contains 
very  fine  pigment-granules,  which  often 
are  quite  red  and  which  are  to  be  seen 
occupying  its  periphery.  When  the  para- 
site has  attained  to  the  size  of  about  one- 
third  of  the  blood-corpuscle,  the  pig- 
ment collects  in  the  middle  or  in  that 
portion  of  the  border  where  amoeboid 
movements  have  ceased.  Following  the 
massing  of  the  pigment  in  this  manner 
in  in  a  dark,  quiescent  clump  the  para- 
siie  breaks  up  into  a  limited  number  of 
very  small  spores.  Occasionally  the  or- 
ganism attains  a  considerable  size  and  at 


the  time  of  its  sporulation  may  occupy 
almost  the  entire  blood-corpuscle.  It 
frequently  happens,  however,  that  the 
corpuscle  becomes  shrunken  and  assumes 
a  brassy  hue.  After  the  infection  has 
continued  for  a  number  of  days  crescents 
are  to  be  observed;  these  may  be  the  or- 
dinary crescentic-shaped  bodies,  the  fusi- 
form bodies  with  pointed  extremities,  or 
the  spherical  bodies  of  this  group. 

The  Unpigmented  Quotidian  Parasite. 
— The  occurrence  of  a  malarial  parasite 
that  completes  its  cycle  of  existence,  even 
to  sporulation,  without  accumulating 
pigment  has  been  described  by  Mar- 
chiafava  and  Celli,  whose  observations 
have  been  confirmed  by  others.  Except 
for  the  absence  of  pigment,  this  parasite 
resembles  the  pigmented  quotidian  para- 
site so  closely  that  the  same  description 
may  answer  for  both.  In  the  eary  stage 
of  its  existence  it  possesses  the  same 
amoeboid  movements  and  completes  its 
cycle  of  development  in  about  the  same 
time,  or,  perhaps,  somewhat  sooner.  As 
in  all  aastivo-autumnal  varieties,  spor- 
ulation is  carried  on  almost  entirely  in 
the  internal  organs.  From  this  form  of 
parasite,  also,  crescents  develop  which, 
of  course,  contain  pigment:  a  character- 
istic common  to  all  members  of  the  cres- 
centic group. 

Colored  Plate  IV.— Fig.  A.  1-32.  Ordi- 
nary tertian  parasite,  showing  staining  of  its 
structure  according  to  the  method  of  Manna- 
berg (picric  acid,  haematoxylin) .  Fig.  B. 
Showing  changes  produced  by  the  administra- 
tion of  quinine.  Fig.  C.  38.  Cerebral  capillary 
with  pigmented  parasites  of  the  second  group 
(from  a  preparation  by  Professor  Celli).  39. 
Cerebral  capillaries  with  unpigmented  sporu- 
lating  parasites  of  the  second  group  (from  a 
preparation  by  Professor  Celli). 

The  Malignant  Tertian  Parasite.  — 
This  variety  of  parasite  was  separated 
from  the  other  forms  by  Marchiafava 
and  Bignami.   In  its  morphological  char- 


468 


MALARIAL  FEVERS.    THE  MALARIAL  PARASITE. 


acteristics  it  resembles  very  closely  the 
pigmented  quotidian  parasite  from  which 
in  many  stages  of  its  development  it  is 
with  difficulty  differentiated.  Marchi- 
afava  and  Bignami  claim  for  it  the  fol- 
lowing points  of  dissimilarity:  1.  Its 
cycle  of  development  continues  forty- 
eight  hours.  2.  The  pigment  sometimes 
shows  oscillatory  movements,  which  do 
not  occur  in  the  quotidian  parasite.  3. 
The  parasite  attains  a  considerable  size 
and  at  the  time  of  sporulation  occupies 
one-half  or  two-thirds  of  the  blood-cor- 
puscle. 4.  In  the  advanced  stages  of 
pigmentation  active  amoeboid  movements 
are  still  to  be  seen.  5.  The  unpigmented 
stage  lasts  over  twenty-four  hours. 

From  the  ordinary  tertian  parasite  the 
malignant  tertian  parasite  differs  in  the 
following  particulars:  1.  In  all  stages 
the  malignant  tertian  parasite  is  smaller. 
2.  It  often  assumes  the  distinct  ring- 
shape  which  the  ordinary  tertian  para- 
site lacks.  3.  Pigment-granules  are  not 
so  numerous  and  only  exceptionally  show 
motion.  4.  The  infected  blood-corpus- 
cles show  a  tendency  to  shrink,  while  in 
the  ordinary  tertian  infection  they  swell 
up.  5.  The  spores  are  smaller  and  not 
so  numerous.  6.  The  pernicious  tertian 
parasite  develops  crescents. 

Degenerate  forms  of  the  sestivo-au- 
tumnal  parasite,  hydropic,  fragmented, 
flagellate,  or  vacuolated,  occur  as  in  the 
other  forms  of  malarial  infection.  These 
are  derived  from  those  parasites  that  fail 
to  properly  mature  and  undergo  seg- 
mentation, particularly  the  extracorpus- 
cular  bodies  which  in  this  variety  of  in- 
fection are  common. 

Infection  with  two  or  more  groups  of 
sestivo-autumnal  parasites,  each  in  a  dif- 
ferent stage  of  development,  is  of  com- 
mon occurrence,  and  a  combined  infec- 
tion with  one  of  the  other  varieties,  es- 
pecially the  tertian,  is  occasionally  seen. 


The  development  of  crescentic,  ovoid, 
or  fusiform  bodies  and  the  significance 
of  their  association  with  aestivo-autumnal 
infections  have  already  been  referred  to. 
These  bodies  are  not  likely  to  be  observed 
in  the  blood  until  the  fever  has  lasted  for 
a  week  or  more;  they  may  persist,  how- 
ever, for  several  weeks  after  other  forms 
of  the  parasite  have  disappeared.  The 
intracorpuscular  origin  of  crescents  has 
been  proved  by  Marchiafava  and  Celli 
and  confirmed  by  many  others,  and,  as 
stated,  they  result  from  the  transforma- 
tion of  intracorpuscular  spherical  forms 
of  aestivo-autumnal  parasites,  which  at 
this  point  fail  to  continue  their  orderly 
cycle  of  development.  Except  rarely, 
only  fully-developed  crescents  are  ob- 
served in  the  circulating  blood,  the  early 
stages  of  intracorpuscular  development 
taking  place  in  the  spleen  and,  especially, 
the  bone-marrow.  They  are  always  pig- 
mented, and  the  pigment,  which  is  very 
dark  in  color  and  usually  in  fine  rods  or 
granules,  is  without  movement  and  is 
collected  in  one  or  two  masses  near  the 
middle  of  the  organism.  In  crescents 
that  are  not  fully  developed  the  pigment 
is  less  regularly  disposed.  From  cres- 
cents flagellate  bodies  may  develop,  but 
only  from  the  round  bodies  of  the  group. 

[According  to  the  view  entertained  by 
Mannaberg,  crescents  are  to  be  regarded 
as  encysted  syzygies  produced  by  the 
conjugation  of  two  parasites  (aestivo- 
autumnal)  and  therefore  capable  of  seg- 
mentation and  reproduction.  This,  how- 
ever, is  not  the  generally-accepted  hy- 
pothesis regarding  the  significance  of 
these  bodies.  The  majority  of  observers 
hold  to  the  view  that,  in  the  human  body 
at  least,  they  exist  as  sterile  forms,  and, 
if  they  possess  any  reproductive  faculty, 
require  for  its  accomplishment  some 
favorable  extracorpuscular  environment. 
Bignami  and  Bastianelli  (Lancet.  Dec.  17. 
'98).  in  their  latest  contribution  to  this 
subject,  arrive  at  these  conclusions:  "We 


MALARIAL  FEVERS.    THE  MALARIAL  PARASITE. 


469 


have,  indeed,  favored  the  idea  that  the 
semilunar  bodies  are  sterile  on  the 
grounds  that  one  never  sees  in  them  any 
form  of  multiplication  and  that  they 
have  no  relation  to  relapses;  and  these 
assertions,  even  in  the  light  of  these  new 
observations,  we  still  hold  by  as  in  ac- 
cordance with  the  truth.  In  other  words, 
we  contended  that  crescents  are  sterile 
bodies  in  man  and  as  far  as  man  is  con- 
cerned. In  fact,  we  put  forward  the  ad- 
ditional hypothesis  that  these  bodies  rep- 
resent those  phases  of  the  life  of  the 
malarial  parasite  Avhich  in  other  para- 
sites are  continued  and  completed  out- 
side of  the  host.  Should  such  migration 
from  the  host  fail  to  occur,  then  that 
phase  of  life  which  cannot  be  completed 
except  in  the  outside  world  or  in  a  new 
host  will  be  carried  out  in  an  abortive 
way  and  will  terminate  in  forms  of  de- 
generation. 

"Certainly  these  new  researches  render 
probable  the  hypothesis  that  the  cycle 
commenced  in  the  blood  of  man  is  com- 
pleted in  some  species  of  mosquito,  but 
they  nevertheless  do  not  negate  the  truth 
of  the  fact  alluded  to  in  our  first  hypothe- 
sis in  those  cases  where  the  passage  from 
man  to  the  new  host  fails  to  take  place." 
James  C.  Wilson  and  Thomas  G.  Ash- 
ton.] 

Flagellation  is  an  occurrence  common 
to  each  of  the  three  principal  varieties 
of  parasites.  It  is  to  be  observed  within 
eight  to  twenty  minutes  after  the  blood 
has  been  withdrawn  from  the  body  and 
does  not  occur  in  the  circulating  blood. 
As  already  pointed  out,  in  aestivo-au- 
tumnal  infection  flagellate  bodies  develop 
only  from  the  spherical  form  of  the  cres- 
cent ic  group,  while  in  tertian  and  quar- 
tan infections  their  origin  is  from  the 
full-grown  extracorpuscular  organisms. 
The  length  of  the  flagella  varies  from 
one-half  the  diameter  of  a  red  blood- 
corpuscle  to  an  extent  three  or  four  times 
longer.  Their  number  may  vary  from 
one  to  six  and  their  attachment  may  be 
to  any  portion  of  the  circumference  of 
the  body.    Free,  detached  flagella  may 


i  also  be  observed.    As  mav  be  surmised, 
I  the  active  movements  of  the  flagella  pro- 
duce a  marked  disturbance  of  the  blood- 
corpuscles. 

According  to  Manson,  flagella  consti- 
tute the  first  phases  of  the  malarial  para- 
site outside  of  man,  and  they  represent 
parasites  in  sporulation  the  spores  of 
which  take  on  this  special  form  of  mobile 
and  flagellated  filaments  "in  the  interest 
J  of  the  extracorporeal  life  of  the  Plas- 
modium." Much  the  same  view  is  en- 
tertained by  Mannaberg,  who  believes 
that  they  represent  a  phase  of  the  sa- 
prophytic existence  of  the  parasite.  Re- 
garding their  internal  structure  we 
possess  no  knowledge  other  than  that 
imparted  by  SacharofT,  who  considers 
the  flagella  as  chromosomes  originating 
in  the  nuclei  of  the  body  of  the  parasite, 
while  the  flagellation  he  regards  as  a 
process  of  perverted  karyokinetic  divis- 
ion accomplished  in  a  violent  manner. 

Literature  of  '96-'97-'98. 

Frequently  in  slides  of  the  blood  of  in- 
fected crows  there  appear,  after  standing 
from  twenty  to  thirty  minutes,  elongated 
motile  forms  such  as  were  described  by 
Danilewsky  as  vermiculi  in  his  "Para- 
sitologic Comparee  du  Sang";  and  in 
order  to  trace  their  origin  it  is  necessary 
to  observe  closely  the  changes  in  the 
other  forms  seen  in  the  blood.  Only  the 
mature  forms  of  the  organism  are  seen  to 
undergo  any  changes  in  the  fresh  slide  of 
blood,  the  half-grown  and  younger  forms 
remaining  unchanged  for  a  long  time. 
The  mature  forms  become  rounded  off, 
and  are  extruded  from  the  corpuscle, 
which  remains  as  a  shadow  in  the  plasma. 

Both  in  the  fresh  and  in  the  stained 
specimens  of  blood  there  can  be  seen  dif- 
ferences which  sharply  distinguish  two 
forms  of  the  organisms.  The  forms  are 
identical  in  outline,  but  the  protoplasm 
of  one  is  granular  and  opaque  as  com- 
pared with  the  clear  hyaline  protoplasm 
of  the  other.     This  distinction  is  well 


470 


MALARIAL  FEVERS.    THE  MALARIAL  PARASITE. 


brought  out  in  the  stained  specimen,  in 
which  the  hyaline  form  remains  almost 
entirely  unstained,  while  the  other  takes 
on  a  well-marked  blue  stain  with  methy- 
lene-blue.  Of  these  it  can  be  determined 
that  the  hyaline  forms  alone  become 
flagellated. 

These  two  forms,  then,  become  ex- 
truded alike  from  the  corpuscle  and  lie 
free  in  the  plasma,  but  generally  only  a 
very  short  time  elapses  before  the  hya- 
line forms  become  flagellated,  according 
to  the  process  so  often  and  so  accurately 
described  by  workers  on  malaria.  The 
granular  forms  lie  quiet  beside  the  nuclei 
and  shadows  of  the  red  blood-corpuscles 
that  lately  contained  them,  but  are  soon 
seen  to  be  approached  by  the  flagella, 
which,  having  torn  themselves  away 
from  the  hyaline  organism  from  whose 
protoplasm  they  were  formed,  struggle 
about  among  the  corpuscles.  These 
flagella,  which  so  concentrate  their  pro- 
toplasm as  to  form  a  head,  swarm  about 
the  granular  spheres,  and  one  of  them 
plunges  its  head  into  the  sphere  and 
finally  wriggles  its  whole  body  into  that 
organism.  Immediately  on  the  entrance 
of  this  flagellum  it  seems  to  become  im- 
possible that  another  should  enter,  for 
they  may  be  watched  circling  about, 
vainly  beating  their  heads  against  the 
organism.  The  flagellum  which  has 
entered  continues  its  activity  for  a  few 
moments  and  the  pigment  of  the  organ- 
ism is  violently  churned  up.  Soon  it  be- 
comes quiet  again,  and  remains  so  for 
from  fifteen  to  twenty  minutes,  when  a 
conical  process  begins  to  appear  at  one 
side  of  the  organism,  the  pigment  col- 
lecting mainly  to  the  opposite  side.  This 
process  grows  larger  and  the  pigment 
becomes  more  and  more  condensed,  until 
finally  we  have  a  fusiform  organism  with 
a  small  spherical  appendage  crowded 
with  pigment  at  one  end.  The  other  end 
is  hyaline,  and  the  pigment-granules 
which  arc  not  crowded  into  the  small 
appendage  arc  distributed  superficially 
over  the  posterior  part  of  the  body.  This 
spindle-shaped  organism  moves  forward 
with  a  gliding  motion,  sometimes  turn 
ing  at  the  same  time  on  its  long  axis, 
sometimes  going  through  amoeboid  con- 
tortions.    Red  corpuscles  lying  in  its 


path  are  either  punctured  by  the  hyaline 
anterior  end,  so  that  the  haemoglobin  is 
enabled  to  escape  into  the  plasma,  or 
passed  over  and  dragged  along  by  the 
adhering  posterior  extremity. 

In  an  intense  infection  a  great  de- 
struction of  corpuscles  occurs;  thus  in  a 
fresh  slide  after  standing  some  time  even 
leucocytes  may  fall  victims  to  the  de- 
structive force  of  these  organisms,  which 
have  been  seen  to  dash  through  them, 
scattering  the  granules  into  the  plasma. 
As  to  the  ultimate  fate  and  true  signifi- 
cance of  these  forms  nothing  definite  can 
as  yet  be  stated.  In  the  slide  they  keep 
in  motion  for  a  long  time,  but  finally 
quiet  down  and  disintegrate.  The  idea 
suggests  itself  from  their  great  power 
of  penetration  that  they  may  be  the 
resistant  forms  that  escape  from  the  body 
during  life  into  the  external  world.  The 
whole  process  described  above  seems  to 
be  a  sexual  process  analogous  to  the 
sexual  process  seen  in  the  lower  animals 
and  plants  which  occurs  under  unfavor- 
able conditions  and  results  in  the  forma- 
tion of  a  resistant  "spore." 

Recently  blood  of  a  woman  suffering 
from  an  infection  with  the  sestivo-autum- 
nal  type  of  organism  in  which  a  great 
number  of  crescents  were  to  be  seen. 
These,  in  the  freshly-made  slide  of  blood, 
with  very  few  exceptions,  retained  their 
crescentic  shape  for  only  a  few  minutes 
(this  activity  in  the  change  of  form 
varies  greatly  in  specimens  of  blood  from 
different  patients).  They  soon  drew 
themselves  up,  thus  straightening  out 
the  curves  of  the  crescent,  while  short- 
ening themselves  into  the  well-known 
ovoid  form.  After  the  lapse  of  from  ten 
to  twenty  minutes  most  of  them  were 
quite  round  and  extracorpuscular,  the 
"bib"  lying  beside  them  as  a  delicate 
circle  or  "shadow  of  the  red  corpuscle." 
After  from  twenty  to  twenty-five  minutes 
certain  of  the  spherical  forms  became 
flagellated:  others,  and  especially  those 
in  which  the  pigment  formed  a  definite 
ring  and  was  not  diffused  throughout  the 
organisms,  remaining  quiet  and  did  not 
become  flagellated.  The  flagella  broke 
from  the  flagellated  forms  and  struggled 
about  among  the  corpuscles,  finally  ap- 
proaching the  quiet  spherical  forms.  One 


MALARIAL  FEVERS.    MANNER  OF  INFECTION. 


471 


of  them  entered,  agitating  the  pigment 
greatly,  sometimes  spinning  the  ring 
about;  the  remainder  were  unable  to 
enter,  but  swarmed  about,  beating  their 
heads  against  the  wall  of  the  organism. 
This  occurred  after  from  thirty-five  to 
forty-five  minutes.  After  the  entrance 
of  the  flagellum  the  organism  again  be- 
came quiet  and  rather  swelled;  but,  al- 
though in  the  two  instances  in  which 
this  process  was  traced  the  fertilized 
form  was  watched  for  a  long  time,  no 
form  analogous  to  the  vermiculus  was 
seen.   MacCallum  (Lancet,  Nov.  13,  '97). 

Phagocytosis.  —  The  destruction  of 
the  malarial  organism  is  effected  partly 
by  the  process  of  phagocytosis  and 
partly  by  the  germicidal  properties  of 
the  blood-plasma,  but  the  relative  im- 
portance played  by  each  is  not,  as  yet, 
entirely  clear.  That  the  blood-plasma 
may  possess  this  effect  is  well  demon- 
strated by  the  destruction  of  the  young 
spores  after  the  exhibition  of  quinine. 
The  cells  chiefly  concerned  in  phago- 
cytosis are  the  large  mononuclear  and 
polymorphonuclear  leucocytes  and  cells 
derived  from  the  spleen,  liver,  and  bone- 
marrow,  termed  macrophages,  as  well  as 
from  the  endothelium  of  the  blood-vessel 
walls.  The  process  is  to  be  best  observed 
by  the  microscopical  examination  of  the 
organs  after  death,  although  during  life 
it  may  be  satisfactorily  studied  in  blood 
withdrawn  from  the  spleen  and,  to  a 
limited  extent,  in  the  peripheral  blood. 
The  phagocytes  may  attack  the  organism 
while  it  is  contained  within  the  red 
blood-corpuscle  and  envelop  both  host 
and  parasite.  The  flagellate  bodies  ap- 
pear to  be  objects  of  particular  attack, 
together  with  cxtracorpuscular  and  vari- 
ous other  degenerated  forms.  As  just 
intimated,  however,  to  the  blood-plasma 
is  to  be  ascribed  an  important  part  in  the 
desi  ruei  ion  of  the  parasites.  This  is  con- 
firmed by  the  fact  that  the  greatest  de- 
struction of  the  parasites  occurs  at  the 


time  of  sporulation,  when  the  young  or- 
ganism is  set  free  in  the  plasma,  and  by 
the  further  fact  that  it  is  at  this  period 
of  the  cycle  of  development  that  quinine 
exercises  its  greatest  influence.  We  may 
conclude,  therefore,  that  the  destruction 
of  the  parasite  is  affected  by  the  com- 
bined action  of  the  blood-plasma  and  the 
phagocytes. 

Literature  of  '96-'97-'98. 

The  lymphocytes  are  never  phagocytic 
in  malaria.  Those  holding  the  opposite 
view  have  been  misled  by  the  fact  that 
normally  there  exists  a  lymphocytic  pig- 
mentation which  is,  therefore,  a  physi- 
ological not  a  pathological  condition. 
Patrick  Manson  (Brit.  Med.  Jour.,  Sept. 
24,  '98). 

Manner  of  Infection.  —  Since  the 
discovery  of  the  malarial  parasite  much 
work  has  been  done  looking  to  a  solu- 
tion of  the  problem  of  the  manner  in 
which  infection  of  the  body  takes  place 
and  the  channels  through  which  the  or- 
ganism enters.  This  is  one  of  the  most 
important  of  the,  as  yet,  unsolved  prob- 
lems relating  to  malaria,  and  until  its 
solution  is  attained  an  effective  prophy- 
laxis cannot  be  hoped  for. 

It  is  agreed  that  infection  may  pos- 
sibly take  place  by  the  entrance  of  the 
parasite  through: — 

1.  The  digestive  tract  (the  water- 
theory). 

2.  The  respiratory  tract  (the  air- 
theory). 

3.  The  skin  (the  inoculation-theory). 

1.  Although  many  believe  that  mala- 
ria may  be  conveyed  into  the  system 
through  the  digestive  tract  by  means  of 
infected  water,  the  weight  of  evidence 
is  overwhelmingly  against  the  probabil- 
ity that  infection  occurs  by  this  channel. 
To  prove  it  the  experiment,  to  be  con- 
clusive, must  be  made  upon  a  person  who 
has  had  no  previous  exposure  to  malaria 


472 


MALARIAL  FEVERS.    MANNER  OF  INFECTION. 


and  who  at  the  time  must  be  removed 
from  any  other  possible  malarial  influ- 
ences, and  after  the  administration  of 
the  supposedly-infected  water  the  blood 
must  be  properly  examined  for  the  pres- 
ence of  the  parasite. 

[Celli  (quoted  by  Mannaberg:  Noth- 
nagel's  Spec.  Path.  u.  Ther.,  B.  2,  T.  2, 
S.  94),  in  the  Hospital  of  S.  Spirito, 
Rome,  caused  several  persons  to  drinK 
water  derived  from  the  pontine  marshes 
and  from  the  marshes  in  the  regions 
surrounding  Rome,  for  a  number  of  days, 
and  none  of  them  developed  malaria. 
Brancaleone  (quoted  by  Mannaberg: 
Nothnagel's  Spec.  Path.  u.  Ther.,  B.  2, 
T.  2,  S.  94)  pursued  the  same  experi- 
ment in  Sicily  with  the  same  nega- 
tive result.  Zeri  (quoted  by  Manna- 
berg: Nothnagel's  Spec.  Path.  u.  Ther., 
B.  2,  T.  2,  S.  94)  caused  nine  persons  to 
drink  water  derived  from  a  malarious 
region  for  from  five  to  twenty  days ;  the 
dust  derived  from  the  evaporation  of 
water  from  the  same  source  he  caused  to 
be  inhaled  by  sixteen  persons;  and  to 
five  persons  he  gave  rectal  injections  of 
the  infected  water.  None  of  the  persons 
thus  experimented  with  developed  ma- 
laria. Norton  (Johns  Hopkins  Hosp. 
Bull.,  Mar.,  '97),  in  a  recent  review  of  the 
subject,  states  emphatically  that  in  his 
opinion  malaria  is  not  a  water-borne 
disease.  James  C.  Wilson  and  Thomas 
G.  Ashton.] 

Literature  of  '96-'97-'98. 

If  the  transmission  of  malaria  is  aerial 
only,  there  are  certain  localities  close  to 
sources  of  malaria  the  freedom  of  which 
from  infection  cannot  be  explained. 
Transmission  by  drinking-water  con- 
sidered as  more  probable.  Malarious 
countries  have  been  traversed  with  im- 
punity by  drinking  only  boiled  water, 
while  villages  have  witnessed  the  disap- 
pearance of  fever  as  the  result  of  a 
supply  of  pure  water.  Experiments  of 
Marino,  Leri,  and  Baccelli  quoted,  how- 
ever, to  show  that  the  theory  of  water- 
borne  malaria  is  not  altogether  tenable. 
Laveran  (Presse  M6d.,  Jan.  20,  '97). 

2.  The  view  that  the  malarial  parasite 


may  enter  the  system  by  way  of  the 
respiratory  tract  is  still  entertained  by 
many,  who,  in  support  of  their  belief, 
instance  the  supposed  influence  of  the 
winds  in  conveying  the  infection.  The 
evidence  is  decisive,  however,  that,  al- 
though the  winds  may  carry  the  malarial 
organism,  the  distance  through  which 
this  is  probable  is  a  very  limited  one. 
Numerous  instances  are  on  record  of  the 
anchorage  of  ships  a  very  short  distance 
off  the  coast  of  highly-malarious  districts 
without  any  members  of  the  crew,  pro- 
vided they  do  not  land,  contracting  the 
disease.  On  the  other  hand,  should 
members  of  such  ship's  crews  land,  in- 
fection almost  invariably  follows.  Again, 
in  many  instances  the  moderate  elevation 
of  a  residence,  although  surrounded  by 
malarious  swamps,  will  often  prove  ef- 
fective in  preventing  infection;  and  it  is 
well  known  that  in  a  malarious  district 
persons  residing  upon  ihe  ground-floor 
of  a  dwelling  may  become  infected,  while 
those  residing  in  the  upper  stories  will 
escape.  Further,  it  is  well  recognized 
that  the  line  of  separation  of  certain 
malarious  localities  from  the  surround- 
ing healthy  region  is,  for  some  obscure 
reason,  sharply  defined:  a  circumstance 
which  could  not  occur  were  the  malarial 
parasite  suspended  in  the  atmosphere  in 
such  a  way  to  be  taken  into  the  respira- 
tory tract. 

Investigation  of  the  air  in  malarious 
regions,  however,  .has  given  result  that 
tend  to  confirm  the  theory.  Maurel  dis- 
covered in  such  air  an  amoeba  that  he 
failed  to  find  in  non-malarious  air,  and 
the  discovery  of  similar  amoebae  in  the 
nasal  mucus  he  regarded  as  evidence  that 
protozoa  may  be  taken  into  the  system 
by  the  respiration.  Similar  observations 
were  made  by  Grassi  and  Calandruccio 
(Mannaberg),  who  discovered  amoebae  in 
the  nasal  mucus  of  pigeons  which  for 


MALARIAL  FEVERS. 


MANNER  OF  INFECTION. 


473 


several  nights  they  subjected  to  the  ex- 
halations from  swamps  or  malarial  earth. 

It  may  be  stated,  however,  that  the 
evidence  for  and  against  the  respiratory 
theory  of  infection  is  inconclusive,  and 
that  positive  proof  of  either  contention 
is  still  wanting. 

3.  Much  attention  has,  of  late,  been 
given  to  the  study  of  the  skin  as  the 
probable  channel  through  which  infec- 
tion by  the  malarial  parasite  takes  place. 
It  has  been  conclusively  proved  by  in- 
oculation-experiments that  infection  may 
take  place  through  this  structure,  and  in 
addition  that  the  different  varieties  of 
malarial  parasites  have  each  a  more  or 
less  definite  period  of  incubation  when 
infection  is  brought  about  in  this  man- 
ner. This  fact  has  directed  attention  to 
biting  insects — more  particularly  blood- 
sucking insects — as  the  means  by  which 
the  infection  may  be  carried  from  in- 
fected to  uninfected  persons.  The  most 
likely  of  such  insects  is,  of  course,  the 
mosquito,  and  the  manner  in  which  it 
may  act  as  the  intermediate  host  has 
been  the  subject  of  much  recent  experi- 
mentation. 

[The  plausibility  of  the  inoculation- 
theory  is  very  much  enhanced  when  com- 
parisons are  made  between  malaria  and 
other  parasitic  blood-infections  of  man 
and  the  lower  animals.  It  has  recently 
been  shown  by  Bruce,  for  instance,  that 
the  tsetse  fly  disease  of  Africa  is  due  to 
a  flagellate  infusorium,  and  that  the 
fly  by  feeding  upon  an  animal  already 
infected  and  then  biting  a  healthy  ani- 
mal will  act  as  a  carrier  of  the  parasite 
from  the  infected  to  the  uninfected.  In 
Texas  fever,  shown  by  Theobald  Smith 
to  be  due  to  a  protozoon,  another  illus- 
1  ration  is  afforded.  Tn  this  disease  the 
tick  [Bodphilus  bovis)  acts  as  the  inter- 
mediate host,  the  tick  falling  from  in- 
fected animals  gives  birth  to  a  numerous 
progeny,  which,  in  turn,  infect  other  ani- 
mals feeding  in  the  pasture.  (Sternberg, 
American  Surg.  Bull.,  April  10,  '97.)  It 


is  also  well  known  that  the  Filar ia 
sanguinis  liominis  is  carried  from  the 
sick  to  the  well  by  the  mosquito. 

There  are  many  circumstances  associ- 
ated with  the  conditions  under  which 
malaria  prevails  that  may  be  reconciled 
with  the  theory  that  the  mosquito  is  an 
important  factor  in  the  transmission  of 
the  parasite.  Thus,  the  relative  im- 
munity possessed  by  those  sleeping  in  the 
upper  stories  of  a  dwelling  in  a  malarious 
region  is  susceptible  of  explanation  by 
the  limited  extent  to  which  the  flight  of 
mosquitos  is  elevated  above  the  ground. 
Also,  from  the  lessened  resistance  offered 
by  the  tender  skin  of  children  to  the 
bites  of  insects  may  be  explained  the 
greater  frequency  with  which  they  are 
infected  by  malaria  in  comparison  to 
adults.  It  is  only  fair  to  state,  however, 
that  the  advocates  of  the  theory  of  in- 
fection by  the  respiratory  organs  explain 
the  greater  liability  of  children  as  being 
due  to  the  fact  that  they  are  nearer  to 
the  ground  than  those  of  greater  stature 
and  are  therefore  exposed  to  the  infec- 
tion in  a  more  concentrated  form.  The 
fact  that  sleeping  upon  the  ground  in  a 
malarious  region  renders  a  person  par- 
ticularly liable  to  infection  may  be  for 
the  reason  that  he  is  thereby  in  a  posi- 
tion most  likely  to  be  bitten  by  insects. 
Further,  it  is  well  known  that  mosquitoes 
are  unlikely  to  leave  the  region  in  which 
they  are  generated,  and  that  as  soon  as 
a  strong  wind  prevails  they  seek  such 
shelter  that  the  wind  carries  them  for  a 
limited  distance  only.  This  may  explain 
the  very  short  distance  malaria  is  car- 
ried by  the  winds. 

Many  interesting  and  valuable  experi- 
ments have  recently  been  made  relating 
to  the  part  played  by  the  mosquito  in 
the  transmission  of  the  malarial  parasite. 
L.  H.  Warner  (N.  Y.  Med.  Jour.,  vol. 
lxviii,  No.  24,  Dec.  10,  '98),  in  the  study 
of  this  subject,  bacteriologically  exam- 
ined various  specimens  of  water  obtained 
from  the  marshes  of  different  malarious 
regions.  In  each  specimen  he  found  one 
or  more  forms  of  spirilla.  These  spirilla, 
however,  produced  no  growth  when  in- 
troduced into  culture-tubes  of  blood- 
serum  and  kept  in  an  incubator  from 
twenty-four  to  twenty-eight  hours.  Hu- 


MALARIAL  FEVERS.    MANNER  OF  INFECTION. 


man  blood  was  then  collected  from  a 
number  of  persons  by  means  of  a  steril- 
ized hollow  needle  connected  with  the 
bulb  of  a  syringe,  also  sterilized,  and  at 
once  transferred  to  a  blood- serum  cult- 
ure-tube, which  was  then  placed  in  a 
thermostat  and  kept  at  a  temperature 
of  100°  F.  A  number  of  mosquitoes  were 
then  collected  and  kept  in  a  sterilized 
bottle.  From  these  by  means  of  a  plati- 
num needle  he  extracted  some  of  the 
albuminous  poison  with  which  mos- 
quitoes are  charged,  and  inserted  some 
of  it  in  each  of  the  blood-serum  cultures, 
which  were  then  replaced  in  the  thermo- 
stat. Examination  made  after  twenty- 
four  hours  revealed  a  parasite  not  to  be 
differentiated  from  the  malarial  parasite. 
As  a  result  of  these  experiments  he  be- 
lieves the  mosquito  to  be  an  important 
factor  in  infection. 

Most  important  results  in  this  field 
have  very  recently  been  obtained  by  Big- 
nami  (Lancet,  Dec.  3,  10,  '98),  whose  in- 
vestigations have  proved  conclusively 
that  at  least  the  most  important  method 
of  transmission  of  malarial  infection  is  by 
inoculation  through  the  agency  of  the 
mosquito.  Bignami's  earlier  experiments 
yielded  only  negative  results,  and  experi- 
ments conducted  as  recently  as  August, 
1898,  failed  to  give  a  positive  reaction. 
Investigations  conducted  by  Ross,  work- 
ing in  Calcutta,  proving  that  the  "dap- 
pled-winged" or  gray  mosquito  is  the 
only  one  concerned  in  the  infection  of 
birds  with  the  Proteosoma  coccidia,  as 
well  as  the  demonstration  by  Bignami,  1 
Bastianelli,  and  Grassi  of  the  develop- 
ment of  crescents  in  the  middle  intestine 
of  a  particular  species  of  mosquito  (An- 
opheles elaviger),  forced  Bignami  to  the 
conclusion  that  these  inoculation-experi- 
ments failed  because  the  proper  variety 
of  mosquito  was  not  employed.  Follow- 
ing the  publication  of  an  article  by 
Grassi  in  September,  1898,  establishing 
the  fact  that  certain  species  of  mos 
quitoes  were  found  in  malarious  districts 
which  did  not  exist  in  healthy  regions. 
Bignami  repeated  his  experiments  with 
mosquitoes  obtained  from  highly-malari- 
ous districts.  It  is  needless  to  mention 
that  every  assurance  was  had  that  the 
patients,  the  subjects  of  experimentation, 


had  never  been  subjected  to  the  possi- 
bility of  malarial  infection.  The  mos- 
quitoes used  in  the  first  and  unsuccessful 
experiments  were  found  by  Grassi  to  be- 
long to  the  Culex  pipiens,  while  those 
from  which  successful  inoculations  were 
obtained  were  identified  as  the  Culex 
penicillaris,  Culex  malarico  (so  called), 
and  Anopheles  claviger,  these  latter 
species  being  those  found  by  Grassi  in 
malarious  regions,  the  Culex  pipiens  be- 
ing the  predominating  species  in  regions 
non-malarious. 

Bignami's  experiment  was  begun  on 
September  26,  '98,  and  on  November  1st 
following  the  patient  was  seized  with  a 
severe  chil1  The  subsequent  symptoms 
were  those  characteristic  of  an  sestivo- 
autumnal  infection  and  the  success  of  the 
experiment  was  fully  demonstrated  by 
finding  in  the  blood  the  sestivo-autumnal 
parasite.  James  C.  Wilson  and  Thomas 
G.  Ashton.] 

Literature  of  '96-'97-'98. 

At  the  present  time  there  are  only  two 
theories  as  to  the  mode  of  transmission 
of  malarial  infection  which  are  worthy 
of  consideration, — namely,  that  it  occurs 
aerially  or  else  by  inoculation  through 
the  agency  of  suctorial  insects.  Welch 
(Johns  Hopkins  Hosp.  Bull.,  Mar.,  '97). 

Transmission  of  malaria  is  by  the  mos- 
quito. Infection  occurs  chiefly  at  night. 
Where  there  are  no  mosquitoes,  there  is 
no  malaria.  Thus  there  is  a  small  island 
in  German  East  Africa  which  is  free  of 
mosquitoes,  and  is  also  free  of  malaria. 
The  L'samba  region,  at  a  certain  height, 
is  also  free  of  malaria.  It  is  also  free  of 
mosquitoes.  R.  Koch  (Deutsche  med. 
Woch.,  June  18,  '98). 

Mosquitoes  not  considered  as  essential 
for  the  conveyance  of  the  parasites:  they 
are  not  numerous  in  the  fever-stricken 
districts  on  the  West  Coast  ;  only  appear 
for  a  short  period  in  the  year.  Surg.- 
Capt,  Duggan  (Lancet,  Mar.  27.  "97). 

While  mosquitoes  are  almost  confined 
to  tropical  and  subtropical  regions,  ma- 
laria has  a  much  wider  area  of  incidence. 
A  mosquito-  and  a  malaria-  map  would 
be  by  no  means  correspondent  in  area, 
the  former  covering  a  much  smaller  tract 
of  country  than  the  latter.    In  seasonal 


MALARIAL  FEVERS.    GENERAL  SYMPTOMATOLOGY. 


475 


charts,  too,  the  occurrence  of  malaria 
would  be,  with  spring  and  autumn  rises, 
continuous;  that  of  mosquitoes,  or  their 
representatives  in  temperate  regions, 
would  be  intermittent.  William  Sykes 
(Brit.  Med.  Jour.,  Jan.  1,  '98). 

The  malarial  parasite  cannot  be  de- 
pendent upon  man  for  its  existence,  be- 
cause it  is  sometimes  present  in  regions 
that  were  previously  uninhabited.  This 
cannot  be  explained  by  simply  stating 
that  the  plasmodium  lives  and  multiplies 
in  the  soil,  and  that  man  is  merely  an 
accidental  host,  for  it  would  then  be  diffi- 
cult to  see  how  such  a  soil-parasite  could 
adapt  itself  so  perfectly  to  an  animal 
organism,  such  as  that  of  man;  and  it 
cannot  be  assumed  that  a  mosquito  or  a 
gnat  may  serve  as  the  host,  for  the  in- 
troduction of  one  malarious  patient  into 
a  district  will  not  suffice  to  start  an  epi- 
demic of  the  fever  unless  the  suitable 
mosquito  is  at  hand  to  carry  the  disease 
about.  Andrew  Davidson  (Edinburgh 
Med.  Jour.,  Oct.,  '98). 

Whatever  views  may  be  entertained 
regarding  other  channels  of  infection, 
the  following  statement  of  Bignami  well 
expresses  the  present  status  of  the  sub- 
ject. "This  much,  at  any  rate,  we  can 
assert,  namely:  that  inoculation  is  the 
only  mechanism  of  infection  which  has 
been  demonstrated  experimentally." 

General  Symptomatology. 

Period  of  Incubation.  —  No  fixed 
period  of  incubation  can  as  yet  be  given 
to  malaria  acquired  in  the  natural  way. 
While  in  the  majority  of  cases  it  would 
appear  to  average  from  six  to  fourteen  or 
twenty  days,  yet  instances  have  been  re- 
ported in  which  the  disease  developed 
within  a  few  hours  after  exposure  to  the 
infection,  and  still  other  instances  in 
which  the  evidences  of  infection  did  not 
occur  for  weeks  or  months  after  exposure. 
In  i lie  former  class  of  cases,  as  studied  by 
Plehn,  the  earliest  evidences  of  supposed 
infection  consisted  of  a  single  paroxysm 
immediately  after  exposure,  no  other 


paroxysms  being  experienced  for  several 
days  subsequently.  At  the  time  of  the 
first  paroxysm  examination  of  the  blood 
yielded  negative  results,  the  parasite  not 
being  discovered  until  the  paroxysms  re- 
curred, some  days  later.  Instances  of 
prolonged  incubation  are  susceptible  to 
the  explanation  that  they  are,  in  all 
probability,  cases  of  relapses  of  earlier 
attacks  that  have  been  characterized  by 
manifestations  so  mild  as  to  be  over- 
looked. 

In  view  of  our  present  knowledge  of 
malaria  some  degree  of  variation  in  the 
length  of  incubation  may  readily  be  ac- 
counted for  by  the  varying  periods  re- 
quired for  the  development  of  the  differ- 
ent forms  of  parasites.  Further,  inas- 
much as  the  clinical  manifestations  of 
the  disease  begin  when  the  parasite  has 
developed  into  a  group  sufficiently  large 
to  produce  a  reaction  at  the  time  of  spor- 
ulation,  the  period  of  incubation  will  also 
vary  in  accordance  with  the  number  of 
parasites  originally  introduced  into  an 
individual.  This  partial  dependence  of 
the  duration  of  the  period  of  incubation 
upon  the  number  of  parasites  producing 
the  infection  is  well  shown  in  the  cases 
in  which  infection  is  artificially  brought 
about  by  inoculation. 

Inoculation-experiments  as  determin- 
ing the  duration  of  incubation  of  malaria 
have  been  of  much  interest,  and  the  vary- 
ing results  obtained  in  infection  by  the 
different  forms  of  parasites  correspond 
to  the  differences  noted  in  cases  that  oc- 
cur spontaneously. 

[Mannaberg  makes  the  following  de- 
ductions from  the  results  of  his  experi- 
ments: In  five  cases  inoculated  with  the 
quartan  parasite  the  minimum  period  of 
incubation  was  11  days,  the  maximum 
period  18  days,  and  the  mean  period  13.4 
days. 

Seven  cases  inoculated  with  the  tertian 
parasite  showed  a  minimum  incubation- 


476 


MALARIAL  FEVERS.    GENERAL  SYMPTOMATOLOGY. 


period  of  6  days,  a  maximum  of  21  days, 
and  a  mean  of  11  days. 

Seven  cases  inoculated  with  the  sestivo- 
autumnal  parasite  (with  amoebae,  but 
without  crescents)  gave  a  minimum 
period  of  incubation  of  3  days,  a  maxi- 
mum of  14  days,  and  a  mean  of  6.5  days; 
while  two  cases  inoculated  with  crescents 
without  ("probably  a  few")  amoebae  gave 
an  incubation  period  of  13  and  15  days, 
respectively,  or  a  mean  of  14  days. 
James  C.  Wilson  and  Thomas  G.  Ash- 
ton.] 

These  experiments  indicate  that  the 
longest  periods  of  incubation  are  associ- 
ated with  the  milder  forms  of  .infection, 
and  that  the  grave  infections,  the  aestivo- 
autumnal,  show  the  shortest  periods. 
In  both  instances  inoculation-experi- 
ments coincide  with  clinical  experience, 
and  render  easy  of  belief  the  probability 
that  in  the  malignant  cases  of  yestivo- 
autumnal  infection  the  incubation  may 
be  brief. 

Clinical  Types. — Mannaberg  divides 
the  malarial  fevers  into  two  main  groups: 
(1)  the  fevers  due  to  infection  with  the 
ordinary  tertian  and  quartan  parasites 
of  Golgi;  (2)  the  fevers  due  to  infection 
with  the  sestivo-autumnal  or  crescent- 
forming  parasite. 

Under  these  two  main  groups,  which 
may  also  be  termed,  respectively,  the 
regularly  intermittent  fevers  and  the 
more  irregular,  often  continued  or  sub- 
continued,  fevers,  may  be  differentiated 
three  separate  types  of  fever:  1.  Tertian 
fever,  single  and  double  infections.  2.  ! 
Quartan  fever,  single,  double,  and  triple 
in  lections;  both  types  comprising  the 
first  group  of  fevers.  3.  The  second 
group  of  fevers,  the  aestivo-autumnal. 

Tertian  fever  is  of  common  occurrence 
in  almost  all  malarial  districts.  The 
quartan  type,  while  the  common  fever  in 
a  few  malarial  regions,  such  as  certain 
parts  of  Sicily,  is  in  most  regions,  where 
other  varieties  of  infection  are  common,  I 


of  rare  occurrence.  The  following  table 
is  given  by  Mannaberg  to  illustrate  the 
infrequent  occurrence  of  this  type  in  dif- 
ferent parts  of  the  world: — 

Cisps  of    Cases  of 

Reporter.  Place.  vSSriV  Q,lart:ln 

Maillot  Bone,  Algiers .  .  2338  26 

Finot  Blidah  4211  21 

Durand  de  Lunel  .  Tenes                 625  6 

Osier  Baltimore           616  5 

Laveran  Algiers              311  7 

Griesinger  Tubingen           414  3 

Mannaberg  Vienna               144  4 

^Estivo-autumnal  form  of  severe  grade 
predominates  in  tropical  and  subtropical 
regions,  and  as  these  regions  are  departed 
from  appears  only  in  the  late  summer 
and  autumn  months;  while  the  less  se- 
vere forms,  tertian  and  quartan  fevers, 
occur  earlier  in  the  season. 

Tertian  Fever. —  Single  Infection, 
or  Tertian  Intermittent  Fever. — In 
this  form  of  fever  the  infection  is  with  a 
single  group  of  tertian  parasites,  each  in- 
dividual member  of  which  is  in  approxi- 
mately the  same  stage  of  development; 
so  that  segmentation  of  all,  with  which 
the  paroxysm  is  associated,  takes  place  at 
about  the  same  time.  As  already  stated, 
the  time  necessary  for  the  completion  of 
the  cycle  of  development  of  the  tertian 
parasite  is  about  forty-eight  hours,  some- 
times a  little  more,  sometimes  a  little  less,, 
the  latter  more  commonly  than  the  for- 
mer. 

The  Paroxysm. — The  paroxysm  may 
j  be  divided  into  three  stages:  the  chill,, 
the  fever,  and  the  sweating  stage. 

The  Chill. — Unpleasant  feelings,  ill- 
defined  sensations  of  discomfort,  usually 
precede  the  chill,  and  in  an  individual 
who  has  ever  experienced  a  malarial  out- 
break are  peculiarly  significant  of  what 
is  about  to  follow.  Even  at  this  time 
1  some  elevation  of  the  temperature  may 
be  noted.  Occasionally  the  onset  is  ab- 
I  rupt  and  without  premonitory  manifesta- 


MALARIAL  FEVERS. 


GENERAL  SYMPTOMATOLOGY. 


477 


tions.  Gradually  the  chill  develops 
from  chilly  sensations  up  and  down  the 
back  early  in  the  paroxysm  until  the  fully  j 
developed  rigor  is  attained.  There  is  j 
then  chattering  of  the  teeth  and  general 
shaking  of  the  body,  often  so  violent  as 
to  shake  the  bed  upon  which  the  patient 
is  lying.  While  the  surface  of  the  body 
is  cold,  and  the  skin,  owing  to  the  erec- 
tion of  the  hair-follicles,  presents  the  con- 
dition of  goose-flesh,  the  internal  tem- 
perature, as  determined  in  the  rectum, 
is  high,  often  105°  or  106°.  The  skin  is 
pale,  often  bluish  in  color,  and  visual  dis- 
turbances, headache,  dizziness,  nausea, 
and  vomiting  are  common.  The  pulse  is 
tense,  small,  and  accelerated.  The  quan- 
tity of  urine  is  increased.  The  duration 
of  the  chill  is  variable,  usually  from  ten 
minutes  to  half  an  hour,  or  an  hour,  or 
even  longer. 

The  Fever. — The  febrile,  or  hot,  stage 
gradually  supervenes  upon  the  stage  of 
chill,  until  by  repeated  flushes  of  heat  the 
stage  of  chill  is  completely  superseded, 
and  the  patient  throws  off  the  additional 
bed-clothing  which  a  short  while  before 
was  so  gratefully  accepted.  The  skin  be- 
comes hot,  dry,  and  reddened,  and  a  sense 
of  burning  heat  is  complained  of;  the 
conjunctivae  are  suffused;  the  pulse 
rapid,  full,  and  bounding;  intense  head- 
ache, dizziness,  and  noises  in  the  ears  are 
often  complained  of;  thirst,  restlessness, 
and  occasionally  delirium  occur,  or  the 
patient  may  be  drowsy  and  somnolent. 
Constipation  is  generally  present;  epis- 
1  axis,  diarrhoea,  and  vomiting  are  among 
the  less  frequently  occurring  symptoms. 
Cutaneous  manifestations  are  of  common 
occurrence,  more  particularly  herpes  of 
the  lips  and  nose,  while  erythema  and 
urticaria  are  sometimes  seen.  Tn  most 
cases  the  splenic  tumor  may  readily  be 
detected.  The  duration  of  this  stage  is 
usually  four  or  five  hours,  and  the  tem- 


perature now  attains  its  greatest  eleva- 
tion. 

The  Sweating  Stage. — With  the  initia- 
tion of  this  stage  the  patient  experiences 
great  relief.  At  first  perspiration  is  no- 
ticed to  occur  about  the  forehead  and 
upon  the  face,  but  shortly  spreads  over 
the  whole  body,  usually  becoming  most 
profuse.  The  temperature  rapidly  falls, 
so  that  in  two  or  three  hours  it  has 
reached  a  subnormal  point,  where  it  gen- 
erally remains  for  some  time.  Great  re- 
lief from  the  distressing  symptoms  of  the 
preceding  stages  is  experienced,  the  pulse 
rapidly  lessens  in  frequency,  and  the  pa- 
tient sinks  into  a  refreshing  sleep. 

The  Intermission. — The  intermission 
continues  until  the  young  parasites  de- 
rived from  the  segmentation  that  has 
caused  the  first  paroxysm  have,  in  their 
turn  passed  through  their  cycle  of  de- 
velopment until  the  stage  of  segmenta- 
tion is  attained,  and  with  it  occurs  the 
second  paroxysm.  The  time  thus  occu- 
pied is  forty-eight  hours,  longer  or 
shorter,  resulting  in  anticipation  or  re- 
tardation of  the  paroxysm.  During  the 
intermission  the  temperature  remains 
subnormal  for  some  hours  and  the  pa- 
tient experiences  great  relief. 

Double  Infection  or  Quotidian  In- 
termittent Fever. — In  the  blood  will 
be  found  two  groups  of  tertian  parasites 
in  different  stages  of  development  and 
reaching  maturity  or  the  stage  of  segmen- 
tation upon  alternate  days.  In  conse- 
quence, quotidian  or  daily  paroxysms 
occur,  which  do  not  differ  in  their  clinical 
manifestations  from  the  paroxysms  in- 
cident to  single  tertian  infection.  Inas- 
much as  one  group  may  be  larger  than 
the  other  at  the  time  of  infection,  it  is 
not  uncommon  for  the  paroxysms  to  be 
tertian  in  typo  until  the  smaller  group 
has  attained  sufficient  size  to  cause  a 
paroxysm.    Further,  as  one  group  may. 


478 


MALARIAL  FEVERS.    GENERAL  SYMPTOMATOLOGY. 


throughout,  be  more  numerous  than  the 
other,  it  is  not  uncommon  for  the  parox- 
ysms produced  by  this  group  to  be  more 


M   F  M 
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IVI 

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HO  WKLS 

movements 

Urine 
Daily  Am?  1 

F. 
107° 

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e 

S 

S105* 

J  104° 

O 

103° 
102° 

101  ° 

100° 
99° 

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DayofDis, 
Pulse. 
Resp. 
Date. 

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L35° 


Temperature-chart  of  double  tertian  infec- 
tion, quotidian  paroxysms.  {Philadelphia 
Hospital.) 


severe  than  those  produced  by  the  other. 
It  is  usual,  also,  for  one  group  of  para- 
sites to  undergo  segmentation  at  a  differ- 
ent hour  from  the  other  group,  resulting, 
of  course,  in  a  constant  difference  in  the 
hour  of  onset  of  the  paroxysms. 

Infection  with  multiple  groups  of 
parasites  is  so  rare  as  to  be  of  no  clin- 
ical importance.  Such  an  occurrence,  of 
course,  would  give  rise  to  a  very  irregular 
type  of  fever.    (See  temperature-chart.) 

Quartan  Fever. — -Single  Infection. 
— The  paroxysm  in  quartan  fever  is  simi- 
lar in  every  respect  to  that  occurring  in 
tertian  fever.   Examination  of  the  blood 

I  shows  the  presence  of  a  single  group  of 
quartan  parasites  the  members  of  which 
are  about  in  the  same  stage  of  evolution 
and  attain  the  stage  of  segmentation  at 
about  the  same  time.  The  time  required 
for  the  completion  of  the  cycle  of  devel- 
opment is  about  seventy-two  hours;  so 
that  the  paroxysms,  coincident  as  they  are 
with  the  segmentation  of  the  parasites, 
occur  every  fourth  day,  an  intermission 
of  two  full  days  existing  between.  The 
paroxysm  is  characterized  by  the  three 
stages  of  chill,  fever,  and  sweating,  and 
are  of  an  average  duration  of  about  ten 
or  twelve  hours.  They  occur  with  great 
regularity  and  show  but  little  tendency 
toward  retardation  or  anticipation.  (See 
comparative  temperature-charts.) 

Double  Infection,  or  Double  Qua  r- 
tan  Fever.  —  This  occurs  when  two 
groups  of  quartan  parasites  exist  in  the 
blood  at  the  same  time,  and  attain  the 
stage  of  segmentation  upon  successive 
days.    In  this  manner  one  day  of  inter- 

:  mission  then  follows.  Upon  examination 
of  the  blood  the  existence  of  these  two 

i  groups  can  be  readily  observed.  The 
paroxysms,  which  occur  upon  two  suc- 
cessive days  followed  by  a  day  of  inter- 
mission, are  in  every  respect  similar  to 
those  occurring  in  single  infection. 


MALARIAL  FEVERS.    GENERAL  SYMPTOMATOLOGY. 


479 


Triple  Infection  or  Triple  Quar- 
tan Fever. — This  is  due  to  the  existence 
in  the  blood  of  three  groups  of  quartan 
parasites  in  different  stages  of  develop- 
ment and  segmenting  upon  successive 
days.  This  results  in  daily  paroxysms,  or 
a  quotidian  intermittent  fever,  which 
only  an  examination  of  the  blood  will 
serve  to  differentiate  from  the  quotidian 
intermittent  fever  due  to  infection  with 
two  groups  of  tertian  parasites.  The  par- 
oxysms are  clinically  similar  to  those 


with  many  exceptions  in  which  the  tend- 
ency to  spontaneous  recovery  is  seen, — 
pass  on  to  a  fatal  termination  with  the 
development  of  pernicious  symptoms 
when  left  to  themselves. 

This  group  of  fevers,  of  course,  de- 
pends upon  infection  with  the  asstivo- 
autumnal  parasite  and  clinically  is  to  be 
observed  in  many  forms.  Two  principal 
forms,  however,  may  be  recognized: 
quotidian  intermittent  fever  and  cestivo- 
autumnal  tertian  fever,  or  malignant  ter- 


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Quartan  simplex:   Silvestrini.  (Mannaberg.) 


already  described  as  occurring  in  the 
single  and  double  infections. 

iEstivo-autumnal  Fever.  —  The  most 
important  particular  in  which  the  fevers 
of  this  group  differ  from  the  regularly- 
intermittent  fevers  is  the  marked  tend- 
ency which  they  show  to  become  per- 
nicious. The  regularly  -  intermittent 
fevers  when  untreated  tend  to  spontane- 
ous recovery,  and  rarely,  except  in  the 
most  intense  infections,  develop  grave, 
pernicious  symptoms.  The  rcstivo-au- 
tumnal  infections,  however, — of  course 


tian  fever.  Owing  to  the  marked  irregu- 
larity which  is  a  characteristic  of  almost 
all  aBstivo-autumnal  fevers,  it  is  not  al- 
ways possible  to  sharply  classify  the  vari- 
ous cases.  The  chief  reasons  for  the 
tendency  toward  irregularity  in  this  in- 
fection are:  1.  The  cycle  of  development 
of  the  parasites  is  not  so  nearly  simul- 
taneous in  the  different  members  of  the 
group  as  it  is  in  the  regularly-intermit- 
tent fevers,  and  as  a  result  sporulation  is 
not  completed  in  the  short  space  of  a 
few   hours,  but  continues  to  occur  for 


480 


MALARIAL  FEVERS.    GENERAL  SYMPTOMATOLOGY. 


twenty-four  to  thirty-six  hours.  The 
consequence  is  the  prolongation  of  the 


paroxysm.  2.  The  different  parasites  do 
not  all  take  the  same  length  of  time  to 
attain  maturity,  as  is  the  case  in  the 
regularly-intermittent  fevers,  but  show 
a  marked  tendency  toward  the  hastening 
of  sporulation,  with  resulting  anticipa- 
tion of  the  succeeding  paroxysm.  3.  Sev- 
eral generations,  though  seldom  more 
than  two,  and  mixed  infections  are  of  fre- 
quent occurrence.  (Mannaberg.) 

In  quotidian  intermittent  fever 
of  the  aestivo-autumnal  type  the  daily 
paroxysms  may  be  so  well  defined  that 
without  an  examination  of  the  blood  it 
may  be  impossible  to  differentiate  it  from 
double  tertian  or  triple  quartan  infec- 
tions. This  is  not  the  rule,  however,  for 
usually  the  paroxysm  is  much  longer  in 
duration,  possibly  twenty-four  hours, 
while  a  chill  may  not  mark  the  onset  or 
may  be  very  slight  and  not  occur  for 
some  time  after  the  temperature  has  be- 
come elevated.  As  a  result  of  one  of  the 
causes  just  mentioned,  after  a  -few  parox- 
ysms the  febrile  movement  no  longer 
conforms  to  a  type,  but,  from  the  pro- 
longation of  one  of  the  paroxysms  or  the 
anticipation  of  the  one  succeeding,  be- 
comes so  irregular  that  the  interval  mark- 
ing the  intermission  becomes  effaced  or 
exists  only  as  a  slight  fall  in  the  tem- 
perature.   (See  temperature-chart.) 

Malignant  tertian  fever,  so  desig- 
nated by  Marchiafava  and  Bignami  to 
distinguish  it  from  tertian  fever  of  the 
regularly-intermittent  type,  is  character- 
ized by  paroxysms  occurring  approxi- 
mately every  forty-eight  hours.  These 
observers  describe  the  temperature-curve 
as  possessing  the  following  peculiarities: 
A  rapid  rise,  frequently  without  a  chill; 
with  slight  fluctuations  the  temperature 
remains  high  for  several  hours  and  then, 
not  infrequently  in  the  middle  of  a  par- 
oxysm, sustains  a  considerable  drop,  but 
not  to  normal  (pseudocrisis):  soon  after, 


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MALARIAL  FEVERS.    GENERAL  SYMPTOMATOLOGY. 


481 


sometimes  with  a  slight  chill,  the  tem- 
perature again  rises,  often  higher  than  it 
was  at  first,  and  after  remaining  there 
for  some  time  finally  falls  to  normal  or 
below.  The  curve  is  thus  divided  by 
Marchiafava  and  Bignami  into:  the  rise, 
the  pseudocrisis,  the  precritical  elevation, 
and  the  true  crisis. 

In  the  intervals  between  the  paroxysms 
the  temperature  is  frequently  subnormal; 
inasmuch,  however,  as  the  paroxysms  not 
uncommonly  last  thirty-six  hours,  or 
more,  these  intermissions  are  of  very  short 
duration.  Although  the  paroxysms  may 
occur  at  intervals  of  longer  duration  than 


that  is  continuous.  Even  in  these  cases, 
however,  it  is  usual  for  the  temperature 
to  show  slight  fluctuations  indicative  of 
the  termination  and  onset  of  the  various 
paroxysms*. 

These  cases  of  malarial  remittent  or 
continued  fever  pass  into  a  condition 
closely  resembling  typhoid  fever,  and 
under  the  name  of  typho-malaria  have 
been  the  source  of  much  confusion  in 
their  proper  differentiation  from  typhoid 
fever.  At  the  present  day,  and  from  the 
foregoing  description  of  the  manner  in 
which  these  cases  occur,  it  seems  un- 
necessary to  call  attention  to  their  essen- 


Quartan  triplex:    Marchiafava  and  Bignami.  (Mannaberg.) 


forty-eight  hours,  it  much  more  fre- 
quently happens  that  anticipation  of  the 
succeeding  paroxysms  occurs,  so  that  the 
periods  of  intermission  become  so  short 
that  the  temperature-curve  becomes  al- 
most continuous,  interrupted  only  by 
slight  depressions  or  remissions'  to  mark 
the  interval  between  the  paroxysms.  In 
this  manner  occur  the  so-called  malarial 
remittent  fevers.  In  consequence  of 
marked  prolongation  of  the  paroxysms 
or  decided  anticipation  of  succeeding 
paroxysms,  so  that  one  paroxysm  begins 
before  the  preceding  one  is  completed, 
many  cases  show  a  temperature-curve 


tially  malarial  nature.  These  cases  of 
aestivo-autumnal  fever  may  suddenly  de- 
velop pernicious  symptoms  at  almost  any 
period  of  their  course.  They  frequently 
so  resemble  typhoid  fever  that  the  dis- 
tinction between  the  two  is  only  possible 
as  the  result  of  a  microscopical  exami- 
nation of  the  blood.  The  patient  may 
complain  of  headache  and  general  body 
pains,  or  there  may  be  decided  delirium 
or  mental  hebetude  and  somnolence. 
Very  grave  cerebral  symptoms  may  at 
any  time  occur,  such  as  stupor  and  coma; 
and  convulsions,  either  general  or  local, 
may  be  observed. 


Intractable  vomiting, 


4—31 


MALARIAL  FEVERS.    GENERAL  SYMPTOMATOLOGY. 


BO  IVHJOS 

NUMBER  Of  , 

movements 

Urine 
Daily  AnVt 


M 


M 


M 


M 


M 


M 


M 


M 


M 


c. 

T42 


F. 

107° 

106° 
105° 


•41 


-40 


-39 


38 


37 


-36 


l-35c 


Temperature-chart  of  eestivo-autumnal  fever,  quotidian  paroxysms. 
( Philadelphia  Hospital.) 


MALARIAL  FEVERS.    GENERAL  SYMPTOMATOLOGY. 


483 


jaundice,  and  profuse  diarrhoea,  together 
with  a  dry,  coated  tongue  and  a  collec- 
tion of  sorcles  about  the  mouth  complete 
the  resemblance  to  enteric  fever. 

Of  79  cases  of  typhoid  fever  treated  to 
conclusion  during  the  sixth  year  of  the 
Johns  Hopkins  Hospital  work,  there  were 
13  that  began  with  shaking  chills.  In 
2  cases  there  were  several  severe  rigors, 
in  3  cases  there  were  two,  while  in  8  the 
rigor  was  single.  Osier  (  Univ.  Med.  Mag., 
Nov.,  '95). 

Literature  of  '96-'97-'98. 

In  a  type  of  autumnal  fever  that  ap- 
pears annually  between  the  10th  and  15th 
of  August  in  Virginia,  and  continues 
until  hard  frost  has  set  in  symptoms 
analogous  to  typhoid  fever  are  often  wit- 
nessed. The  temperature-curve  of  this 
prolonged  remittent  type  and  that  of 
typhoid  fever  are  almost  identical,  while 
many  of  the  prodromal  symptoms  are 
similar.  There  are,  however,  no  iliac 
gurgling,  no  rose  spots;  no  tympanites, 
but  rather  retraction  of  the  abdomen; 
and  no  intestinal  haemorrhage.  The  only 
test  is  the  recognition  of  the  malarial 
parasite.  Bedford  Brown  (Charlotte  Med. 
Jour.,  Jan.,  '97). 

It  is  often  hard  to  exactly  differentiate 
existing  conditions  into  symptoms  di- 
rectly associated  with  malaria  and  dis- 
eases consequent  on  malaria.  Diseases 
may  exist  at  the  same  time  as  the  ma- 
laria, or  may  be  induced  by  it;  and  only 
such  conditions  should  be  classified  as 
symptoms  as  are  the  common  conditions 
existing  in  malaria — for  example,  chills 
followed  by  fever,  headache,  sweating, 
vomiting,  epistaxis,  herpes  labialis,  bron- 
chitis, and  albumin  in  the  urine.  All 
these  occur  sufficiently  often  to  make 
them  characteristic  of  malaria  when  a 
number  are  taken  together.  Rupert  Nor- 
ton (Amor.  Jour.  Med.  Sciences,  Feb., 
'98). 

Typho-malarial  fever  is  not  a  special 
type  of  fevers,  but  represents  a  group  of 
hybrids  between  typhoid  fever  and  ma- 
laria] fevers.  Woodward  (National  Med. 
Review,  May,  '98). 

At  the  Johns  Hopkins  Hospital  in  Bal- 
timore, where  hundreds  of  cases  of  ty- 


phoid fever  and  of  malarial  fever  are  seen, 
many  coming  from  the  neighboring  Ches- 
apeake-Bay region  and  from  the  South- 
ern States,  the  "typho-malarial"  fever  of 
Southern  writers  is  unknown,  and  only 
two  cases  of  true  combined  typhoid  and 
malarial  infection  have  been  seen.  The 
reports  from  foreign  countries  in  general 
are  the  same.  I.  P.  Lyon  (Amer.  Jour. 
Med.  Sciences,  Jan.,  '99). 

Particular  mention  must  be  made  of 
those  cases  of  aastivo-autumnal  fever 
which  are  not  characterized  by  a  definite 
paroxysm  and  in  which  but  a  slight  ele- 
vation of  temperature  occurs,  and  that 
irregularly.  The  patients  in  whom  this 
irregularly-manifested  infection  occurs 
may  complain  only  of  headache,  pain  in 
the  back  and  limbs,  loss  of  appetite,  and 
lassitude.  This  condition  is,  of  course, 
accompanied  by  enlargement  of  the 
spleen,  the  characteristic  malarial  an- 
aemia, and  the  presence  in  the  blood  of 
asstivo-autumnal  parasites. 

Pernicious  Malarial  Fever.— The  de- 
velopment of  pernicious  characteristics 
in  malarial  infections  depends  probably 
upon  one  or  more*  of  several  conditions. 
These  predisposing  factors  are  divided  by 
Mannaberg  into:  (1)  individual  predis- 
position; (2)  peculiarities  of  the  para- 
sites; (3)  anatomical  lesions. 

1.  There  are  persons  who  appear  to 
possess  a  special  predisposition  to  the  de- 
velopment of  pernicious  symptoms  upon 
exposure  to  infection,  and  who  as  often 
as  they  are  taken  ill  with  malaria  develop 
the  disease  in  one  of  its  severe  forms.  It 
is  probable  that  in  such  subjects  certain 
peculiarities,  either  chemical  or  anatom- 
ical, may  favor  the  elaboration  of  malarial 
toxins  of  more  potent  effect,  or  may  influ- 
ence (he  accumulation  of  infected  blood- 
corpuscles  within  certain  capillary  areas. 
In  others  the  predisposition  may  be  tem- 
porary ot  acquired,  as  in  alcoholics,  those 
exposed  to  excessive  heat,  or  bodily  weak- 


484 


MALARIAL  FEVERS.    GENERAL  SYMPTOMATOLOGY. 


ness  incident  to  overwork  and  deficient 
nourishment.  It  has  also  been  observed 
that  certain  conditions  predispose  to  the 
reference  of  pernicious  symptoms  to  cer- 
tain organs.  Thus,  it  is  observed  by  Bac- 
celli  that  those  whose  work  exposes  them 
to  the  sun's  heat  frequently  develop  the 
comatose  form,  and  that  the  same  is  true 
of  alcoholic  subjects,  while  persons  pre- 
viously suffering  from  intestinal  catarrh 
are  very  likely  to  develop  the  choleriform 
type.  In  a  highly-malarious  region 
strangers  who  are  unaccustomed  to  the 
climate  are  much  more  likely  to  develop 
pernicious  malaria  than  the  natives  or 
those  who  have  become  acclimated. 

2.  Pernicious  malarial  fever  is  invari- 
ably due  to  infection  with  one  of  the 
varieties  of  parasites  belonging  to  the 
second,  or  sestivo-autumnal,  group,  and 
of  these  varieties  the  one  most  frequently 
concerned,  according  to  Marchiafava  and 
Bignami,  is  the  malignant  tertian  para- 
site. This  being  accepted  as  a  fact,  ma- 
lignancy is  found  still  further  to  depend 
upon  the  number  of  parasites  existing  in 
a  given  infection.  In  pernicious  cases, 
while  the  number  of  parasites  will  be 
found  to  vary  considerably,  their  number 
is  always  great.  That  the  number  alone 
is  sufficient  to  explain  malignancy  many 
authorities  dispute,  and,  while  admitting 
the  importance  of  their  effect,  the  claim 
is  made  that  pernicious  symptoms  arise 
in  certain  infections  as  the  result  of  a 
higher  degree  of  toxicity  or  virulency 
possessed  by  the  infecting  parasites. 

3.  The  different  anatomical  lesions  in 
pernicious  malarial  fever  are  sufficient  to 
account  for  many  of  the  malignant  mani- 
festations; these  depend,  for  the  most 
part,  upon  the  occlusion  of  the  lumina 
of  the  blood-vessels  with  the  infected 
blood-corpuscles.  Thus,  by  way  of  illus- 
tration, as  a  result  of  obstruction  in  the 
cerebral  vessels  numerous  punctiform 


|  haemorrhages  ensue  and  grave  cerebral 

|  symptoms  occur. 

Pernicious  malarial  fever  may  show  it- 
self as  such  from  the  very  onset,  and  this 
is  particularly  so  in  highly  malarious 
regions,  or  the  occurrence  of  pernicious 
symptoms  may  be  preceded  by  several 
ordinary  paroxysms.  From  what  has 
been  said  regarding  the  localization  of 
the  malarial  parasites  in  the  vascular 
system  of  certain  organs,  it  may  readily 
be  understood  that  more  or  less  distinct 
types  can  be  differentiated.  The  most 
frequently  occurring  type  is  the  coma- 
tose. 

Comatose  Form.  —  In  this  form  the 
earliest  manifestation  may  be  suddenly 
oncoming  coma;  unconsciousness  is  pro- 
found and  respiration  stertorous  and  ir- 
regular, so  that  in  many  instances  a 
striking  resemblance  to  apoplexy  is  pro- 
duced. More  frequently,  however,  coma 
does  not  ensue  until  after  the  occurrence 
of  one  or  more  paroxysms  uncomplicated 
with  cerebral  symptoms,  or  associated, 
perhaps,  only  with  slight  delirium  and 
somnolence.  Then,  with  deepening  stu- 
por or  increasing  delirium,  coma  super- 
venes. In  other  instances  coma  inter- 
mits, beginning  with  the  elevation  of 
temperature  associated  with  the  parox- 
ysm, and  ceasing  with  its  decline,  and 
this  may  repeat  itself  several  times.  In 
by  far  the  greatest  number  of  cases,  how- 
ever, coma  continues,  at  times  with  occa- 
sional periods  of  slight  improvement,  and 
may  thus  last  for  three  or  four  days  until 
either  death  or  recovery  terminates  the 
case. 

In  the  comatose  form  of  malarial  fever 
the  temperature-curve  conforms  to  no 
particular  type.  The  face  is  usually 
I  deeply  congested,  or  may  be  pale  if  the 
pernicious  symptoms  occur  in  a  person 
suffering  from  the  anaemia  incident  to 
previous  malarial  infections.    The  pupils 


MALARIAL  FEVERS.    GENERAL  SYMPTOMATOLOGY. 


485 


may  be  dilated  or  contracted  and  usually 
react  to  light;  occasionally  they  are  un- 
equal. The  pulse  may  show  increased 
frequency,  or  may  be  slow,  and  is  usu-  | 
ally  of  high  tension,  although  it  may  be 
weak  and  compressible,  especially  toward 
the  end  of  the  paroxysm.  The  respira- 
tion may  be  increased  or  decreased  in  fre- 
quency and  stertorous,  and  is  frequently 
irregular,  conforming  to  the  Cheyne- 
Stokes  type.  The  skin  is  hot  and  dry, 
and  toward  the  end  of  the  paroxysm 
may  be  bathed  in  profuse  perspiration. 
Occasionally  petechias  are  observed,  and 
slight  jaundice  is  not  uncommon.  Cer- 
tain muscles  may  be  the  seat  of  local 
spasms,  as  evidenced  by  the  occurrence 
of  trismus  or  deviation  of  the  eyeballs. 
Involuntary  evacuation  of  faaces  and 
urine  occurs,  although  urinary  retention 
is  frequent.  With  the  decline  of  the 
fever,  coma,  with  the  associated  symp- 
toms, disappears,  and  recovery  may  result 
from  what  is  apparently  the  most  pro- 
found infection.  A  second  paroxysm 
rapidly  follows  the  first  unless  energetic 
treatment  be  instituted,  and  this  gen- 
erally proves  fatal.  In  other  cases  of  this 
type  of  pernicious  malarial  fever  delir- 
ium of  a  wild  maniacal  character  may 
occur,  and  hallucinations  and  delusions 
are  not  infrequently  seen.  In  still  other 
cases  convulsions  of  a  tetanic  character 
(perniciosa  comatosa  tetanica)  are  to  be 
observed,  and  paralyses,  hemiplegic  or 
localized,  are  not  uncommon. 

Algid  Form. — Usually  after  several 
preceding  paroxysms  lacking  indications 
of  anything  extraordinary,  the  symptoms 
of  the  algid  type  set  in.  These  do  not 
occur  during  the  cold  stage,  but  usually 
immediately  afterward,  during  the  period 
of  fever.  At  that  time  the  patient  passes 
into  a  condition  of  profound  collapse. 
Arterial  tension  becomes  at  once  lowered 
and  the  pulse  is  very  compressible  or,  ] 


later,  imperceptible.  The  eyes  are 
sunken,  the  pupils  dilated,  the  counte- 
nance drawn,  assuming  the  Hippocratic 
expression.  The  mind  remains  clear,  the 
lips  are  cyanosed,  the  tongue  dry  and 
cold;  the  surface  of  the  skin  is  extremely 
cold  and  covered  with  a  cold  sweat;  the 
rectal  temperature  is  elevated.  The  pa- 
tient complains  of  extreme  prostration 
and  of  a  distressing  sense  of  internal 
heat,  but  does  not  appear  to  notice  the 
coldness  of  the  surface  of  the  body;  he 
is  extremely  apathetic  and  apparently 
unaware  of,  or  indifferent  to,  the  danger 
that  threatens  him.  The  abdomen  be- 
comes retracted,  and  by  palpation  the  en- 
larged spleen  may  usually  be  detected; 
the  heart-sounds  are  weak  and  feeble  to 
the  point  of  being  inaudible.  The  symp- 
toms are  not  dissimilar  to  those  charac- 
terizing Asiatic  cholera,  and  in  a  few 
hours  death  may  terminate  the  case. 

Syncopal  Form.  —  In  this  form  the 
chief  symptom  is  the  occurrence  of  at- 
tacks of  syncope.  The  patient  cannot 
make  the  slightest  exertion,  even  turning 
from  one  side  to  the  other,  or  merely 
lifting  the  hand,  without  at  once  pass- 
ing off  into  a  condition  of  syncope.  Ex- 
treme weakness  is  complained  of,  the 
pulse  is  small,  readily  compressible,  and 
accelerated.  Should  recovery  from  the 
first  paroxysm  take  place,  and  treatment 
fail  to  prevent  the  onset  of  the  second, 
death  is  then  almost  certain  to  occur. 
This  form  is  closely  related  to  the  algid 
form. 

Sudoriferous  Form. — This  type  also 
belongs  to  the  algid  group  of  pernicious 
fevers,  profuse  and  excessive  sweating  oc- 
curring during  the  last  stage  of  the  par- 
oxysm; in  many  instances,  however, 
the  sweating  occurs  shortly  after  the 
beginning  of  the  febrile  stage,  producing 
the  impression  that  the  paroxysm  is  to 
be  shortened  in  duration.   The  contrary, 


486 


MALARIAL  FEVERS. 


GENERAL  SYMPTOMATOLOGY. 


however,  is  the  case,  as  in  this  type  the  I 
paroxysm  is  usually  greatly  prolonged. 
With  the  onset  of  excessive  sweating  the 
patient  rapidly  passes  into  a  state  of  col-  I 
lapse,  with  coldness  of  the  surface  and 
feeble,  compressible  pulse.  This  condi- 
tion becomes  progressively  worse  and 
terminates  fatally  unless  relieved. 

Cakdialgic  and  Gastralgic  Form. 
— This  form  is  characterized  by  severe 
epigastric  pains  occurring  during  the 
paroxysm,  usually  commencing  in  the 
febrile  stage  and  disappearing  with  its 
termination.  The  pain  is  sometimes  re- 
flected to  the  vertebral  column  and  is 
frequently  associated  with  vomiting, 
haematemesis,  a  sense  of  choking,  and 
hiccough.  Intestinal  symptoms  may  oc- 
cur, but  not  invariably.  The  patient  J 
Aery  shortly  passes  into  a  condition  of  i 
collapse,  with  weak  pulse,  coldness  of  the 
surface,  cyanosis,  and  symptoms  similar 
to  those  occurring  in  the  algid  form. 

Choleriform  Type.  —  The  principal  ' 
symptoms  of  this  form  are  vomiting, 
profuse  diarrhoea,  and  fever.   At  first  the 
stools  may  be  faecal  in  character,  but  soon 
become  serous,  flecked  with  blood,  and  | 
contain  shreds  of  cast-off  mucous  mem-  | 
brane.     Severe   abdominal   pains  and 
cramps  in  the  extremities  are  common; 
the  surface  becomes  cold  and  moist,  the 
pulse  thread-like,  and  the  extremities 
and  face  cyanosed;  the  clinical  picture  j 
closely  simulates  the  algid  stage  of  Asi- 
atic cholera.   These  symptoms  have  their 
basis  in  the  localization  of  the  parasites 
in  the  gastro-intestinal  tract,  the  blood- 
vessels in  the  mucous  membrane  of  which  I 
are  found  to  be  so  choked  with  parasites 
that  actual  thrombosis  may  be  produced, 
resulting   in   necrosis    and  ulceration. 
This  form  is  one  of  the  most  commonly 
met  with  types  of  pernicious  fever  in 
the  malarious  regions  of  tropical  and 
subtropical  climates. 


Bilious  Form.  —  The  fever  in  this 
form  is  usually  of  malignant  tertian  type, 
although  at  the  beginning  several  well- 
defined  quotidian  or  ordinary  tertian  par- 
oxysms may  occur.  In  this  event,  how- 
ever, the  fever  soon  becomes  remittent 
or  subcontinuous.  The  onset  is  fre- 
quently unmarked  by  a  chill,  and  the 
sweating  is  often  absent  and  insignifi- 
cant. The  vomiting  of  a  large  amount 
of  bile-stained  material  is  one  of  the 
chief  symptoms,  and  is  often  uncon- 
trollable. The  stools  are  often  deeply 
bile-stained,  but  may  be  serous  and  at 
times  are  bloody.  Epigastric  pain  and, 
later  in  the  case,  hiccough  are  common. 
Jaundice  is  one  of  the  most  frequent  as 
well  as  important  symptoms;  profound 
disturbance  of  the  nervous  system — as 
evidenced  by  delirium,  stupor,  coma, 
and  ataxic  phenomena — is  frequently  ob- 
served. Epistaxis  and  haematemesis  also 
occur.  The  urine  is  deeply  discolored 
with  bile  and,  owing  to  the  profuse  vom- 
iting and  diarrhoea,  is  usually  scanty. 
Uninfluenced  by  treatment,  the  case  may 
continue  for  a  week  or  ten  days,  and  in 
spite  of  the  most  active  treatment  may 
terminate  fatally  in  one  or  two  days. 

Hemorrhagic  Form.  —  Although  of 
infrequent  occurrence,  a  few  of  these 
cases  have  been  reported.  They  are  char- 
acterized by  extensive  haemorrhages  into 
the  skin,  epistaxis,  profuse  bleeding  from 
the  gums,  or  haemoptysis. 

Literature  of  '96-'97-'98. 

Among  soldiers  of  the  Madagascar  ex- 
pedition, twelve  cases  of  malarial  retinal 
haemorrhage,  in  all  of  which  the  cause 
was  undoubtedly  malaria.  Albuminuria, 
cardiac  diseases,  and  other  conditions  ex- 
cluded as  etiological  factors.  The  haemor- 
rhages occurred  suddenly,  without  pain- 
ful phenomena,  either  at  the  height  of  the 
attack  or  in  the  subsequent  period  of 
anaemia  or  cachexia:  and  in  most  of  the 
patients  the  spleen  was  much  enlarged. 


MALARIAL  FEVERS. 


GENERAL  SYMPTOMATOLOGY. 


487 


The  site  of  the  haemorrhage  was,  in  the 
majority  of  the  cases,  elos^  to  the  disk, 
the  macula  being  also  affected  in  some 
cases.  In  five  out  of  the  twelve  cases  the 
lesion  was  unilateral,  and  there  was  usu- 
ally more  than  one  patch.  The  blood  was 
absorbed  rather  rapidly,  and,  in  the  ma- 
jority of  the  cases,  great  improvement  in 
vision  occurred  simultaneously.  These 
haemorrhages  attributed  to  parasitic 
thrombi,  though  the  blood  may  have 
escaped  through  the  wall.  Basseres 
(Arch.  d'Oph.,  June,  '96). 

Pneumonic  Fokm.  —  It  is  probable 
that  in  this  form  there  is  a  distinct  local- 
ization of  the  parasites  in  the  capillaries 
of  the  lungs.  The  onset  is  usually  char- 
acterized by  a  marked  chill,  followed  by 
a  rapidly-rising  temperature;  severe  pain 
may  be  experienced  and  referred  to  a 
particular  part  of  the  thorax.  Marked 
dyspnoea,  cyanosis,  and  cough  accom- 
panied with  scanty  expectoration,  con- 
sisting at  times  of  blood-streaked  mucus, 
are  striking  phenomena.  Physical  ex- 
amination results  in  no  signs  of  a  local 
lesion:  simply  diffused,  fine  bronchial 
rales  unassociated  with  bronchial  breath- 
ing. 

Literature  of  '96-'97-'98. 

There  is  no  such  thing  as  a  malarial  in- 
termittent pneumonia  nor  a  remittent 
pneumonic  fever,  nor  a  pernicious  pneu- 
monic fever.  Laveran  (Amer.  Jour.  Med. 
Sci.,  Feb.,  '98). 

Malarial  Hematuria;  Febiis  Biliaris; 
Hemoglobinuria ;  Black- water  Fever. — 

This  form  of  pernicious  malarial  fever 
occurs  especially  on  the  east  and  west 
coasts  of  Africa,  and  particularly  in  Mad- 
agascar. In  Europe  it  is  of  uncommon 
occurrence  except  in  Greece,  where  it  is 
frequently  seen;  isolated  instances  of  it 
are  also  observed  in  Italy  and  the  neigh- 
boring islands.  It  would  appear  from 
the  mass  of  evidence  that  the  disease 
occurs  only  in  those  persons  who  have 


I  resided  in  highly-malarious  regions  for 
a  considerable  period  of  time  and  who 

j  have  experienced  previous  attacks  of 
malaria.  Mannaberg  is  of  the  opinion 
that  it  rarely  occurs  during  the  first  six 
months  of  residence  in  a  malarious  dis- 
trict. It  would  thus  appear  that  by  re- 
peated infection  with  malaria  an  indi- 
vidual predisposition  is  produced  to  this 
particular  form  of  the  disease,  although 
just  what  the  conditions  are  creating  this 
predisposition  is  not  satisfactorily  ex- 
plained. It  is  claimed  by  some  that 
ansemia  is  the  chief  causal  factor.  It 
would  appear,  however,  that  from  some 
toxic  substance  present  in  the  circula- 

j  tion,  possibly  produced  by  the  parasite 
itself  (Baccelli),  such  destruction  of  red 
blood-corpuscles  ensues  that  the  haemo- 
globin is  set  free  in  the  blood-serum  in 
such  enormous  quantities  that  the  liver 
cannot  dispose  of  it,  and  hasmoglobi- 
nuria  results. 

The  blood  shows  the  presence  of  the 
aestivo-autumnal  parasite  as  the  exciting 
cause.  The  infrequency  with  which,  the 
affection  is  observed  in  temperate  cli- 
mates has  led  to  the  belief  that  the  con- 
ditions appertaining  to  a  tropical  climate 

j  are  necessary  for  its  development.  Any- 
thing which  lowers  the  vitality  of  the  in- 
dividual, such  as  alcoholism,  may  consti- 
tute an  important  predisposing  factor. 
Syphilis  is  held  to  possess  a  particular 
influence,  owing  to  the  analogy  between 

I  paroxysmal  hematuria  and  malarial 
hematuria.  Physical  fatigue  and  men- 
tal emotions  are  supposed  to  exert  a  cer- 
tain influence.  Changing  from  one  lo- 
cality to  another  in  malarious  regions  is 

!  at  times  followed  by  an  attack  of  the 
disease.  An  important  role  has  been  as- 
signed by  many  to  quinine  in  producing 
the  hauuoglobinuric  paroxysm. 

[That  this  drug  may  have  an  unfavor- 
able influence  has  been  the  subject  of  in- 


MALARIAL  FEVERS.    GENERAL  SYMPTOMATOLOGY. 


vestigation  of  many  observers,  and  it  is 
thought  by  Plehn  (Deutsch.  Med.  Hist., 
Nos.  25  to  28,  '95)  that  its  administration 
is  often  the  determining  cause  of  hsemo- 
globinuria; he  further  demonstrates  that 
his  cases  of  hsemoglobinuria  treated  with 
quinine  did  not  pursue  such  a  favorable 
course  as  those  treated  with  other  meas- 
ures. It  is  asserted  by  Tomaselli  (Manna- 
berg:  Nothnagel's  Spec.  Path.  u.  Therap., 
B.  2,  T.  2,  S,  215)  that  in  Sicily  he 
has  met  with  no  instances  of  malarial 
hsemoglobinuria  in  which  quinine  has  not 
been  taken  before  the  occurrence  of  the 
paroxysm,  while  Ughetti  (Mannaberg, 
Nothnagel's  Spec.  Path.  u.  Therap.,  P>. 
2,  T.  2,  S.  215)  goes  still  further  and 
holds  to  the  view  that  all  such  cases  are 
in  reality  instances  of  the  toxic  effects  of 
quinine,  and  that  hsemoglobinuria  bears 
no  relation  to  malarial  infection.  The 
majority  of  observers,  however,  do  not 
entertain  these  views.  James  C.  Wilson 
and  Thomas  G.  Ashton.] 

Six  cases  in  which  hsemoglobinuria  re- 
peatedly followed  the  administration  of 
quinine.  None  of  the  patients  could  take 
the  sulphate,  2  could  not  take  cinchona 
in  any  form,  1  not  the  salicylate,  1  not 
the  valerianate,  1  not  the  hydrobromate 
of  quinine,  without  the  recurrence  of 
hsemoglobinuria.  Coromilas  (Jour,  de 
M6d.,  Jan.  25,  '91). 

Literature  of  '96-'97-'98. 

Black-water  fever  is  more  closely  re- 
lated to  yellow  fever  than  to  malaria. 
The  melanuria  occurs  only  after  the  ad- 
ministration of  large  doses  of  quinine; 
and  is  not  a  symptom  of  the  disease,  but 
a  result  of  the  quinine  therapy.  Below 
(Med.  Rec,  Aug.  7,  '97). 

Hsemoglobinuria  of  malaria  attributed 
not  to  the  hsemoparasite,  but  to  its  toxins. 
Quinine  may  bring  it  on  even  in  moder- 
ate doses.  Four  classes  recognized:  (1) 
pernicious  malaria  with  hsemoglobinuria 
cured  by  quinine;  (2)  mild  attacks  of 
malaria  accompanied  by  hsemoglobinuria 
only  when  quinine  is  given;  (3)  hemo- 
globinuria coming  on  in  persons  who  have 
had  malaria  some  time  ago,  and  not  asso- 
ciated with  quinine;  (4)  hemoglobinuria 
produced  by  small  doses  of  quinine  in 
persons  who  have  had  malaria  previously. 


Quinine  should  be  continued  in  spite  of 
the  hsemoglobinuria,  if  the  malarial  at- 
tack require  it.  Persulphate  of  iron  and 
inhalations  of  oxygen  also  recommended. 
Baccelli  (Policlin.,  Jan.  15,  '97). 

The  recently  expressed  opinion  of  Pro- 
fessor Koch  that  hsemoglobinuria  (black- 
water  fever)  is  only  another  name  for 
quinine  poisoning  is  one  calculated  to  do 
much  harm.  Out  of  9  cases  of  black- 
water  fever  personally  treated,  2  were 
fatal;  in  both  the  administration  of  qui- 
nine was  neglected  until  too  late.  All 
the  cases  which  recovered  were  treated 
with  heroic  doses  (30  grains  in  twenty- 
four  hours,  and  the  attack  lasted  four 
days,  the  hsemoglobinuria  subsiding 
gradually.  In  the  other  cases  in  which 
much  larger  doses  were  administered  (GO 
to  120  grains  in  twenty-four  hours)  the 
hamioglobinuria  only  lasted  from  twenty- 
four  to  thirty-six  hours,  and  stopped 
quite  suddenly.  R.  U.  Moffat  (Brit.  Med. 
Jour.,  No.  1969,  Sept.  24,  '98). 

Acute  hsemorrhagic  nephritis  directly 
dependent  on  malaria,  where  the  blood 
has  been  examined  with  positive  findings, 
has  been  noted  by  a  number  of  authors, 
and  there  is  no  doubt  that  it  occurs,  al- 
though the  condition  has  been  attributed 
to  the  effects  of  quinine  given  for  its 
therapeutic  effects  in  very  large  doses. 
But  well-authenticated  cases  are  reported 
where  no  quinine  had  been  given  when 
the  condition  was  first  discovered. 

Hsemorrhagic  nephritis  is  the  possi- 
bility of  a  bacterial  infection's  being 
combined  with  the  malarial.  Rupert  Nor- 
ton (Amer.  Jour.  Med.  Sci.,  Feb.,  '98). 

As  previously  stated,  malarial  hemo- 
globinuria usually  occurs  in  those  who 
have  had  repeated  attacks  of  malaria, 
becoming    evident    during    a  relapse. 

j  Should  it  occur  in  a  primary  infection, 
which  is  rare,  it  is  not  commonly  the 
initial  symptom,  but  is  usually  preceded 
by  a  number  of  paroxysms.  Fever,  hemo- 
globinuria, and  jaundice  are  the  prin- 

!  cipal  clinical  manifestations. 

The  fever  may  vary  greatly  in  differ- 
ent cases;  the  type  may  be  intermittent, 

I  remittent,  or  continuous,  and  the  general 


MALARIAL  FEVERS.    GENERAL  SYMPTOMATOLOGY. 


489 


statement  may  be  made  that,  the  less  the 
tendency  is  to  the  occurrence  of  inter- 
missions or  remissions,  the  more  severe 
is  the  paroxysm.  Unlike  most  forms  of 
gestivo-autumnal  fever,  the  onset  of  the 
paroxysm  is  almost  always  abrupt  and 
is  accompanied  with  a  severe  rigor.  Pro- 
fuse vomiting,  intense  body-pains,  and 
pains  in  the  head  and  extremities  soon 
follow,  the  vomitus  being  dark  and 
deeply  stained  with  bile.  In  many  in- 
stances constipation  occurs,  but  in  the 
graver  forms  there  is  a  tendency  to  pro- 
fuse diarrhoea,  the  dejections  being  dark 
and  bile-stained.  The  pulse  is  rapid  and 
at  first  of  increased  tension,  while  later 
it  becomes  weak  and  compressible.  The 
conjunctivae  are  suffused,  the  face  is 
flushed  and  expressive  of  the  great  anx- 
iety the  patient  is  laboring  under. 

The  urine  varies  greatly  in  specific- 
gravity  and  is  usually  faintly  acid  in  re- 
action. In  the  early  stage  of  the  parox- 
ysm in  which  hemoglobinuria  occurs 
the  urine  is  light  red  in  color.  This 
soon  deepens,  however,  until  during  the 
height  of  the  paroxysm  it  becomes  dark 
brown  or  almost  black.  Owing  to  the 
presence  of  bile,  this  color  is  slightly 
tinged  with  green  and  the  urine  is  frothy 
upon  shaking.  It  is  usually  perfectly 
clear  above  the  dark-brown  sediment 
that  is  deposited  upon  standing.  This 
sediment  is  made  up  of  masses  of  pig- 
ment, mucus,  epithelium  from  the  blad- 
der and  kidneys,  hyaline  and  granular 
epithelial  casts,  and,  unless  the  case  be 
one  of  true  haemoglobinuria,  numerous 
red  blood-corpuscles.  The  amount  of 
urine,  although  generally  reduced,  varies 
greatly,  and  in  severe  cases  may  be  al- 
most entirely  suppressed.  It,  of  course, 
shows  the  presence  of  albumin  in  large 
amounts,  and  in  some  instances  the  pres- 
ence of  biliary  pigments  may  be  detected. 
Inflammation  of  the  kidneys  almost  al- 


ways accompanies,  or  follows,  malarial 
hemoglobinuria,  and  in  some  instances 
proves  rapidly  fatal  with  symptoms  of 
uraemia.  In  mild  cases,  however,  it  is 
slight  and  soon  passes  away. 

In  all  varieties  of  malaria  the  toxicity 
of  the  urine  is  increased  from  the  begin- 
ning to  the  end  of  the  attack,  but  not 
with  any  regularity  of  progression.  The 
more  toxic  the  urine,  the  more  abundant 
the  phosphates  present  and  the  deeper 
the  color.  Pensuti  (Munch,  med.  Woch., 
Nov.  29,  '92). 

Literature  of  '96-'97-'98. 

Conclusions  drawn  from  study  of  758 
cases  of  malarial  fever:  — 

1.  Albuminuria  is  a  frequent  occur- 
rence in  the  malarial  fevers  of  Baltimore, 
occurring  in  46.4  per  cent,  of  our  cases. 

2.  It  is  considerably  more  frequent  in 
gestivo-autumnal  infections  than  in  other 
forms,  occurring  in  58.3  per  cent,  of  these 
instances  against  38.6  per  cent,  in  the 
regularly  intermittent  fevers. 

3.  Acute  nephritis  is  not  an  unusual 
complication  of  malarial  fever,  having 
occurred  in  2.7  per  cent,  of  the  cases 
treated  in  the  wards  of  the  Johns  Hop- 
kins Hospital,  and  in  between  1  and  2 
per  cent,  of  all  cases  seen  at  the  institu- 
tion. 

4.  The  frequency  of  acute  nephritis  in 
sestivo-autumnal  fever  is  much  greater 
than  in  the  regularly  intermittent  fevers, 
having  been  observed  in  4.7  per  cent,  of 
the  cases  treated  in  our  wards  and  in  2.3 
per  cent,  of  all  the  cases  seen. 

5.  The  frequency  of  albuminuria  and 
nephritis  in  malarial  fever,  while  some- 
what below  that  observed  in  the  more 
severe  acute  infections,  such  as  typhoid 
fever,  scarlet  fever,  and  diphtheria,  is  yet 
considerable. 

6.  There  is  reason  to  believe  that  ma- 
larial infection,  especially  in  the  more 
tropical  countries,  may  play  an  appre- 
ciable part  in  the  etiology  of  chronic 
renal  disease.  William  Sydney  Thayer 
(Amer.  Jour.  Med.  Sci.,  Dec,  '98). 

Jaundice  is  a  constant  symptom,  and 
sometimes  occurs  as  a  prodromal  mani- 
festation;   ordinarily,  however,  it  first 


490 


MALARIAL  FEVERS.    GENERAL  SYMPTOMATOLOGY. 


occurs  coincidently  with  the  hsemoglo- 
binuric  paroxysm,  and  becomes  most  in- 
tense during  the  febrile  stage;  it  usually 
continues  for  several  days  following  the 
termination  of  the  paroxysm. 

In  the  milder  cases  decided  remissions, 
or  even  intermissions,  of  the  paroxysms 
occur,  and  with  the  fall  in  temperature 
the  urine  clears  up  and  the  jaundice 
lessens  in  intensity.  From  this  point  re- 
covery may  take  place,  but  usually  re- 
peated paroxysms  follow.  In  the  severe 
forms  the  temperature  remains  continu- 
ous, and  the  intensity  of  the  symptoms 
described  becomes  aggravated  until  a 
condition  of  collapse  supervenes.  Delir- 
ium is  not  usual  and  the  patient  is  anx- 
ious and  apprehensive.  At  times,  with 
almost  complete  suppression,  or  the  se- 
cretion of  a  very  small  amount  of  in- 
tensely-bloody urine,  death  may  occur 
within  several  days.  In  these  cases  algid 
symptoms  may  be  present;  the  pulse 
small,  rapid,  and  weak;  the  surface  of 
the  body  cold  and  bathed  in  cold  per- 
spiration; stupor,  coma,  or  convulsions. 
In  other  cases  profuse  nosebleed,  haem- 
orrhages from  the  mouth  and  bowels,  con- 
si  ant  hiccough,  involuntary  evacuation 
of  faeces,  and  delirium  close  the  scene. 

Relapses.  —  The  occurrence  of  fevers 
after  long  intervals  of  apyrexia  and  ap- 
parent health  has  long  been  recognized. 
Since  the  discovery  of  the  malarial  para- 
site many  observers  have  endeavored  to 
associate  the  occurrence  of  these  cases 
with  infection  by  a  parasite  whose  cycle 
of  development  required  a  much  longer 
period  for  its  completion  than  that  re- 
quired by  the  parasites  already  described. 
It  has  already  been  pointed  out  that  a 
malarial  paroxysm  does  not  follow  1lio 
sporulation  of  a  group  of  parasites  until 
the  group  has  attained  a  sufficient  size 
to  produce  toxic  effects  at  the  time  of 
sporulation.    It  has  also  been  stated,  in 


the  brief  allusion  to  the  process  of  phago- 
cytosis, that  only  a  certain  number  of 
the  young  spores  enter  fresh  corpuscles 
and  complete  again  the  cycle  of  develop- 
ment, and  that  a  considerable  number 
of  them  following  sporulation  are  de- 
stroyed by  some  constituent  of  the  blood- 
plasma  and  by  the  action  of  the  phago- 
cytes. In  this  manner  a  sufficient  num- 
ber of  young  parasites  may  be  destroyed 
to  prevent  the  immediate  recurrence  of 
the  paroxysm,  and  it  is  only  when,  from 
the  parasites  that  have  escaped  destruc- 
tion, a  sufficiently  large  group  has  been 
generated  to  produce  symptoms  that  a 
paroxysm  again  takes  place.  Precisely 
the  same  effect  is  produced  when  malaria 
is  imperfectly  treated  with  quinine,  as, 
for  instance,  the  administration  of  a  sin- 
gle dose  of  the  drug  following  a  parox- 
ysm. A  certain  number  of  spores  are  de- 
stroyed sufficient  to  prevent  the  recur- 
rence of  the  paroxysm  at  the  usual  time; 
the  spores  that  escape  infect  fresh  cor- 
puscles, complete  their  cycles  of  exist- 
ence, until  after  successive  generations 
the  group  has  become  sufficiently  large 
to  produce  a  paroxysm.  It  may  thus  be 
seen  that  the  intervals  marking  the  oc- 
currence of  the  paroxysms  are  prolonged 
and  irregular,  and  may  be  from  five  to 
twelve  days,  or  even  longer.  Fevers  with 
long  intervals  may  result  in  tertian  and 
quartan  infections,  as  well  as  in  aestivo- 
autumnal  infection,  and  they  are  to  be 
regarded  as  relapses,  occurring  in  the 
manner  just  described,  and  not  as  due 
to  a  particular  variety  of  parasites  whose 
cycle  of  development  requires  an  ex- 
traordinarily long  period. 

The  Blood. — The  changes  in  the  blood, 
aside  from  the  presence  of  the  parasites, 
are  largely  dependent  upon  the  destruc- 
tion of  red  blood-cells  and  the  setting 
free  of  haemoglobin.  Tn  all  forms  of 
malaria  a  reduction  in  the  number  of  red 


MALARIAL  FEVERS. 


GENERAL  ETIOLOGY. 


491 


blood-corpuscles  and  in  the  percentage 
of  haemoglobin  follows  each  paroxysm. 
In  asstivo-autumnal  infections  this  re- 
duction is  more  decided  than  in  the  regu- 
larly intermittent  forms,  and  the  tend- 
ency to  restitution  to  the  normal  between 
the  paroxysms  is  not  so  marked.  In  ter- 
tian and  quartan  fevers  the  return  to  the 
normal  number  is  very  rapid. 

The  number  of  white  blood-corpuscles 
is  always  less  than  normal,  and  the  re- 
duction is  always  greatest  just  after  a 
paroxysm.  A  differential  count  shows  a 
decided  relative  decrease  in  the  percent- 
age of  polymorphonuclear  neutrophiles, 
with  a  relative  increase  in  the  percentage 
of  large  mononuclear  leucocytes.  In  cer- 
tain instances  of  pernicious  malaria  a  de- 
cided leucocytosis  has  been  observed, 
doubtless  due,  at  least  in  some  of  these 
cases,  to  secondary  infections.  In  any 
event,  the  occurrence  is  of  unfavorable 
significance. 

General  Etiology. 

Climatic  Conditions. — The  influence 
of  heat  upon  the  development  of  malaria 
is  clearly  shown  in  the  geographical  dis- 
tribution of  the  disease.  It  not  only 
prevails  to  a  much  greater  extent  in 
tropical  and  subtropical  climates,  but  in 
these  regions  it  is  encountered  in  its 
most  intense  forms;  and,  furthermore, 
as  the  temperate  and  colder  climates  are 
approached,  the  prevalence  and  intensity 
of  the  affection  progressively  decline;  so 
that  in  those  latitudes  where  the  mean 
summer  temperature  does  not  exceed 
15-16°  C.  malaria  ceases  to  exist. 

Season. — From  these  remarks  it  may 
readily  be  seen  that  the  effect  of  season 
upon  the  prevalence  of  malaria  exists  in 
its  fullest  extent  only  in  those  regions 
characterized  by  marked  seasonal  differ- 
ences in  the  temperature.  In  the  tropics 
the  disease  prevails  throughout  the  year, 
although  its  greatest  virulence  is  to  be 


I  observed  during  summer  and  autumn, 
while  in  temperate  climates  it  is  of  un- 
common occurrence  in  winter  and  spring. 
In   tropical   and   subtropical  climates, 

|  however,  the  maximum  prevalence  is  at- 
tained in  July,  August,  and  September, 
when  to  the  greatest  elevation  of  tem- 

i  perature  there  is  added  the  maximum 
amount  of  atmospheric  moisture.  It 

|  must  be  borne  in  mind,  also,  that  not 

I  only  the  number  of  cases,  but  also  their 
severity,  is  in  direct  relation  to  the  tem- 
perature elevation.  Thus,  in  temperate 
climates  the  mildest  types  are  to  be  ob- 
served in  the  spring,  and  are  then  due  to 
tertian  and  quartan  infections,  usually 
with  a  single  group.  With  the  approach 
of  summer,  infection  with  more  than  one 
group  of  the  tertian  parasite  becomes  of 
more  common  occurrence,  and  with  the 
beginning  of  July  the  severer  forms  of 

I  fever  due  to  aBstivo-autumnal  infection 
make  their  appearance,  reaching  their 
height  during  August,  September,  and 
October. 

The  recurrence  of  malaria  in  the  win- 
ter and  spring  has  given  rise  to  the  inter- 
esting question  whether  these  cases  are 
'  instances  of  fresh  infection  or  whether 
they  are  relapses  from  infections  received 
during  the  preceding  malarial  period? 
This  question  has  as  yet  received  no  def- 
inite solution,  although  the  experience 
of  most  observers  tends  to  support  the 
view  that,  while  cases  of  primary  infec- 
tion occur  in  the  spring,  such  cases  are, 
of  course,  of  more  common  occurrence 
during  the  more  active  malarial  periods. 
Nevertheless,  it  is  the  experience  of  most 
of  those  entitled  to  an  opinion  that  those 
cases  of  malaria  occurring  in  winter  are 
I  to  be  regarded  as  relapses  from  infection 
I  received  during  the  preceding  summer. 
;  It  is  further  to  be  observed  that  malaria 
;  prevails  to  a  greater  extent,  and  with 
I  more  severe  manifestations,  during  warm 


492  MALARIAL  FEVERS.    GENERAL  ETIOLOGY. 


than  during  cold  summers,  and  especially 
during  warm  summers  accompanied  by 
a  high  degree  of  atmospheric  moisture. 
Heat  alone,  therefore,  is  not  all-sufficient 
for  the  development  of  malaria,  and  only 
becomes  of  etiological  importance  when 
associated  with  other  conditions  pres- 
ently to  be  discussed.  The  truth  of  this 
statement  is  exemplified  in  numerous 
communities  in  tropical  climates  where 
these  combined  conditions  do  not  exist. 

Moisture. — Much  stress  is  to  be  laid 
upon  the  influence  of  moisture  upon  the 
development  of  malaria,  and  this  is  true 
equally  of  atmospheric  moisture  and 
telluric  moisture.  As  above  stated,  in 
malarious  regions  the  number  of  cases  is 
usually  materially  greater  during  a  sum- 
mer attended  by  a  heavy  rain-fall  than 
during  a  dry  summer.  In  tropical  coun- 
tries the  first  notable  increase  in  the 
number  of  cases  occurs  when  the  dry 
season  is  first  terminated  by  the  autumn 
rains,  but  when  the  rainy  season  has  con- 
tinued a  sufficient  length  of  time  to 
more  or  less  completely  inundate  the  sur- 
face of  the  ground  a  decrease  in  the  prev- 
alence of  the  disease  takes  place.  When, 
however,  upon  the  termination  of  the 
wet  season  the  sun  regains  its  full  vigor, 
the  evaporation  of  the  moisture  from  the 
ground  that  ensues  causes  the  number  of 
cases  again  to  become  largely  augmented. 
(Mannaberg.) 

The  Winds. — Although  it  has  been 
asserted  that  the  winds  play  a  certain 
part  in  the  spread  of  the  infection,  they 
cannot  be  regarded  as  having  any  direct 
bearing  upon  the  development  of  mala- 
ria, It  has  been  long  recognized  that  a 
growth  of  trees  along  the  border  of  a 
malarious  district  appears  to  check  and 
limit  the  distribution  of  the  infection  by 
arresting  the  miasmic-ladened  winds. 
This  limitation,  however,  probably  de- 
pends upon  other  conditions  presently  to 


be  described,  and  the  winds  cannot  be 
regarded  as  a  very  important  factor  in 
the  dissemination  of  the  infection. 

Telluric  Conditions.  —  That  the 
condition  of  the  soil  has  some  close  as- 
sociation with  the  development  of  mala- 
ria there  is  much  confirmatory  evidence. 
It  is  a  well-known  fact  that  sailors  and 
others  on  board  ships  anchored  off  shore 
in  even  highly  malarious  regions  escape 
infection,  while  those  from  the  same 
ships  who  land  and  remain  on  shore  but 
for  a  short  period  contract  the  disease. 
This  association  between  the  soil  and 
the  malarial  infection  is  strikingly  illus- 
trated in  those  whose  occupations  call 
for  its  disturbance.  Thus,  in  malarious 
regions  the  infection  is  rife  among  those 
engaged  in  building  railroads,  canals,  and 
kindred  enterprises,  and  is  usually  then 
to  be  met  with  in  its  most  intense  and 
pernicious  forms. 

In  general,  malaria  particularly  pre- 
vails in  low,  marshy  localities  which  are 
rich  in  decaying  vegetable  matters  and 
in  which  the  drainage  is  ineffective.  Salt 
marshes  are  usually  non-malarious,  al- 
though marshes  that  are  alternately  fresh 
and  salt  as  they  may  be  subjected  to  in- 
i  undation  from  neighboring  fresh-water 
streams  and  from  salt  water  at  the  flood 
i  of  the  tide  are  to  be  regarded  as  highly 
I  noxious.  Malaria,  therefore,  is  less  likely 
I  to  prevail  when  the  geological  conditions 
!  of  the  soil  favor  the  rapid  drainage  of 
I  the  moisture,  or  its  prompt  absorption. 
If,  however,  the  conditions  are  such 
that  the  moisture  is  not  rapidly  absorbed 
by  the  soil,  but  is  taken  up  by  evapora- 
tion into  the  atmosphere,  the  disease  pre- 
vails.   In  this  connection  a  subsoil  im- 
pervious to  moisture  is  to  be  regarded 
as  particularly  favorable  to  the  develop- 
ment of  the  infection. 

Disturbance  of  the  soil,  even  in  dis- 
tricts where  the  disease  has  not  pre- 


MALARIAL  FEVERS.    GENERAL  ETIOLOGY.  493 


viously  prevailed,  is  at  times  followed 
by  an  epidemic  of  malaria.  This  asso- 
ciation is,  of  course,  greatly  accentu- 
ated in  regions  already  malarious;  and, 
as  already  pointed  out,  the  excavation  of 
the  soil  in  malarious  regions  for  such 
purposes  as  railway  and  canal  construc- 
tion is  apt  to  be  attended  by  an  outbreak 
of  the  severe  forms  of  the  disease.  This 
is  particularly  liable  to  occur  when  such 
excavations  call  for  the  disturbance  of 
rank  vegetation  or  vegetable  detritus. 

From  what  has  already  been  said,  the 
effect  of  drainage  upon  a  malarious  re- 
gion may  readily  be  surmised.  The  in- 
stances in  which  the  institution  of  a 
proper  drainage  has  been  followed  by 
the  entire  disappearance  of  the  disease 
from  extensive  regions  in  which  it  pre- 
viously thrived  are  now  too  numerous  to 
call  for  particular  mention.  In  rather  a 
direct  ratio  to  the  establishment  of 
drainage  of  marshy  regions  and  their 
subsequent  cultivation  a  corresponding 
improvement  takes  place  in  the  health- 
fulness  of  malarious  districts.  The  plant- 
ing of  trees  has  been  observed  to  be  par- 
ticularly effective  in  accomplishing  this 
result,  but  it  is  not  probable  that  one 
variety  possesses  more  value  in  this  re- 
spect than  another.  The  advantage  of 
a  tree-growth,  therefore,  is  to  be  ascribed 
more  to  the  better  drainage  of  the  soil 
which  it  accomplishes  than  to  any  spe- 
cific power  possessed  by  certain  varieties. 
The  latter  view  was  at  one  time  quite 
largely  entertained,  and  the  marked  im- 
provement in  the  sanitary  conditions  fol- 
lowing the  planting  of  the  Eucalyptus 
globulus  in  certain  malarious  regions  af- 
forded a  basis  for  its  belief.  The  aban- 
donment of  regions  formerly  subjected 
to  a  high  degree  of  cultivation  has  been 
followed  by  malaria,  often  of  a  virulent 
type,  although  previously  the  disease  was 
unknown.    This  fact  is  strikingly  illus- 


trated by  the  Eoman  Campagna,  where, 
I  during  the  period  of  its  cultivation, 
malaria  was  practically  unknown.  From 
the  time  of  its  abandonment,  however, 
to  within  recent  years,  and  even  at  the 
present  day  in  certain  sections,  malaria 
j  prevails  there  with  extreme  intensity. 

Altitude  influences  the  development 
j  of  malaria  to  the  extent  that  with  in- 
|  creasing  elevations  a  corresponding  de- 
crease in  the  prevalence  and  intensity  of 
the  infection  occurs,  and,  even  in  mala- 
rious districts,  those  residing  in  the 
upper  stories  of  dwellings  are  less  liable 
to  the  disease  than  those  whose  living- 
quarters  are  nearer  the  ground.  While 
increasing  elevation  has  the  effect  men- 
tioned, it  must  be  borne  in  mind  that 
malaria    may    prevail    wherever  heat, 
moisture,  and  decaying  vegetable  detritus 
are  to  be  found  associated,  and  the  in- 
crease in  altitude  simply  diminishes  the 
j  chances  for  the  association  of  these  con- 
j  ditions. 

Geographically  malaria  is  a  wide- 
spread disease.  In  America  the  region 
of  its  prevalence  is  gradually  becoming 

I  more  and  more  restricted,  and  in  many 
sections,  notably  the  New  England  States 

j  and  upper  Atlantic  sea-coast,  where  for- 
merly it  prevailed  extensively,  it  has 
now  ceased  to  occur  except  in  the  mildest 
forms.  In  the  Southern  States,  particu- 
larly along  the  gulf  and  the  Mississippi 

I  River,  the  disease  is  almost  constantly 
present,  while  it  is  still  to  be  met  with 
in  certain  regions  about  the  Great  Lakes. 

j  In  Europe,  although  the  disease  is  still 

i  to  be  found  in  parts  of  France,  Germany, 

I  and  even  England,  its  chief  seats  of  ac- 
tivity are  to  be  found  in  certain  regions 
of  Italy  and  in  Southern  Russia.  Trop- 
ical and  subtropical  regions,  however, 
where  the  telluric  and  other  conditions 
already  mentioned  as  favorable  to  its 

I  genesis  exist,  are  the  parts  of  the  world 


494: 


MALARIAL  FEVERS.    PATHOLOGICAL  ANATOMY. 


where  malaria  is  to  be  particularly  en- 
countered and  where  it  more  or  less  con- 
stantly prevails. 

Age  has  no  direct  influence  upon  the 
susceptibility  to  malaria.  Those  in  the 
active  periods  of  life  contract  the  disease 
more  frequently  because  they  are  more 
exposed  to  the  predisposing  causes,  while 
the  very  young  and  the  aged,  only  be- 
cause they  are  less  likely  to  be  exposed, 
enjoy  an  apparent  immunity.  Excep- 
tions to  this  statement  will  presently  be 
noted. 

Literature  of  '96-'97-'98. 

Fatal  case  of  pernicious  malarial 
poisoning  in  a  newborn  infant.  On  morn- 
ing of  the  day  following  delivery,  mother 
had  a  chill.  At  the  same  time  the  child 
became  comatose  and  cyanotic,  cold,  its 
face  blue  and  pinched,  and  finger-nails 
blue,  with  rectal  temperature  103.5°,  and 
had  rapid  respiration.  Victor  Cadwell 
(Amer.  Medico-Surg.  Bull.,  July  25,  '97). 

Case  of  congenital  malaria  when  child 
was  10  weeks  old.  Physical  examination 
showed  the  patient  to  be  much  emaciated, 
pale  and  weak.  Convulsions  occurred 
daily  since  birth.  When  child  was  11 
weeks  old,  blood  was  examined  and  Plas- 
modium malarise  found  in  abundance. 
The  child  was  given  1  grain  of  quinine  by 
the  rectum  in  enema  twice  daily,  and  the 
convulsions  ceased  from  this  time,  but 
muscular  rigidity,  sleeplessness,  colic, 
constipation,  and  restlessness  persisted. 

Since  patient  did  not  improve  nor  gain 
in  weight  after  a  month's  treatment  with 
quinine,  child  was  taken  to  a  non-ma- 
larial place,  where  it  began  to  improve 
immediately.  The  plasmodia  were  prob- 
ably conveyed  directly  by  means  of  the 
foetal  circulation,  although  there  is  a  pos- 
sibility of  infection  by  the  mother's  milk. 
Kenelm  Winslow  (Boston  Med.  and  Surg. 
Jour.,  May  2,  '97)  . 

Enlargement  of  the  spleen  in  children 
is  of  little  diagnostic  value  without  a  cor- 
roborative examination  of  the  blood. 
Quite  severe  cases  of  tertian  malaria  occur 
in  children  in  whom  there  is  no  enlarge 
ment  of  the  spleen,  and  many  cases  in 
which  the  spleen  is  enlarged  are  not  ma- 


larial. Henry  Koplik  (Med.  Record,  Feb. 
5,  '98). 

Eace  appears  to  exercise  a  certain  in- 
fluence upon  susceptibility  to  the  dis- 
ease; thus,  the  native  inhabitants  of 
malarious  regions  appear  to  possess  a 
relative  immunity.  In  America  the 
negro  possesses  this  insusceptibility  to 
a  considerable  degree,  and  it  has  been 
estimated  by  Thayer,  as  the  result  of  his 
observations  in  Baltimore,  that  this  race 
possesses  only  about  one-third  the  sus- 
ceptibility that  the  white  possesses. 

[On  the  other  hand,  Frederick  Smith 
(Brit.  Med.  Jour.,  No.  1981,  Dec.  17,  '98), 
from  a  study  of  immunity  as  illustrated 
by  the  incidence  of  the  disease  on  various 
races  in  Sierra  Leone,  concludes  that, 
while  there  is  such  a  thing  as  immunity, 
it  is  only  of  a  relative  kind,  and  that  such 
immunity  as  exists  is  acquired.  From  this 
stand-point,  be  believes  that  the  negro 
possesses  no  special  immunity.  James  C. 
Wilson  and  Thomas  G.  Ashton.] 

Occupation  is  of  considerable  impor- 
tance in  its  bearing  upon  susceptibility. 
Those  whose  pursuits  entail  disturbance 
of  the  soil  in  malarious  districts,  such  as 
farmers,  railway-laborers,  and  the  like 
are  particularly  liable.  Also  those  who 
are  obliged  to  approach  the  swampy 
banks  of  rivers  and  inlets,  such  as  fisher- 
men, are  rendered  susceptible.  Soldiers, 
probably  because  they  sleep  upon,  or  in 
close  proximity  to,  the  ground  are  very 
susceptible,  as  the  malarial  infection,  as 
is  well  known,  tends  to  cling  to  the  soil. 

Pathological  Anatomy. 

Acute  Malarial  Infections. — Our 
knowledge  of  the  pathological  changes 
in  acute  malarial  infections  is  necessarily 
!  largely  derived  from  a  study  of  the  con- 
dition of  the  internal  organs  as  found  in 
the  grave  forms  of  sestivo-autumnal  in- 
fection, as  cases  of  quartan  and  tertian 
infections  rarely  reach  the  post-mortem 
I  table. 


MALARIAL  FEVERS.    PATHOLOGICAL  ANATOMY. 


495 


Melanosis  due  to  the  accumulation  of 
pigment  derived  from  the  haemoglobin 
by  the  action  of  the  parasites  constitutes 
one  of  the  most  significant  anatomical 
changes.  The  distribution  of  pigment 
in  the  various  organs  imparts  to  them  a 
peculiar  slaty-gray  color,  which  is  char- 
acteristic. Neither  the  malarial  pigment 
nor  the  malarial  parasite  is  distributed 
in  the  various  organs  with  any  degree  of 
regularity.  Not  only  is  this  irregularity 
manifested  in  different  cases  of  infection 
with  the  same  variety  of  parasite,  but  it 
has  already  been  pointed  out  that  in  in- 
fection with  the  quartan  parasite  the 
peripheral  blood  appears  to  contain  the 
organism  in  greatest  number,  while  in 
tertian  infection  to  a  certain  extent  and 
in  sestivo-autumnal  infection  •  to  an  al- 
most exclusive  extent  the  parasites  are  to 
be  found  in  the  blood-vessels  of  the  in- 
ternal organs.  It  thus  becomes  evident, 
not  only  that  melanosis  varies  in  differ- 
ent cases,  but  that  pathological  changes 
dependent  upon  the  presence  of  the  para- 
sites are  also  irregularly  distributed.  It 
is  also  to  be  remarked  that  this  varying 
distribution  of  the  parasites  in  all  prob- 
ability has  an  important  bearing  upon 
the  clinical  manifestations. 

Pigment  is  found  to  accumulate  to  a 
greater  extent  in  the  capillaries  than  in 
the  blood-vessels  of  larger  calibre,  and 
the  same  is  true  of  the  pigment-laden 
parasites.  Especially  is  the  accumula- 
tion marked  where  the  blood-current  is 
retarded  by  the  lessening  of  the  calibre 
of  the  blood-vessel  at  the  point  where 
the  artery  merges  into  the  capillary. 
Melanosis,  therefore,  as  well  as  para- 
sitic congestion,  may  be  looked  for  in  the 
capillaries  of  the  cerebral  convolutions, 
the  dura  mater,  the  pulmonary  alveoli, 
the  intestinal  villi,  and  the  glomeruli  of 
the  kidneys.  Ordinarily,  however,  the 
blood-vessels  of  the  spleen,  liver,  and 


brain  show  the  greatest  accumula- 
tions. 

Literature  of  '96-'97-'98. 

Characteristic  effects  due  to  long-con- 
tinued malarial  poisoning  are  mainly  ob- 
served only  in  the  liver,  spleen,  and  kid- 
neys. These  effects  are  of  two  kinds: 
pigmentary  and  cirrhotic.  In  the  former 
black  and  yellow  pigment  is  found  dis- 
tributed through  the  organ,  while  in  the 
latter  the  organ  presents  a  thickening  of 
its  stroma  and  a  growth  of  new  con- 
nective tissue;  and  in  each  organ  the 
pigmentary  changes  are  mainly  found  in 
the  less  chronic,  and  the  cirrhotic  in  the 
more  chronic,  cases.  L.  F.  Cliilde  (Indian 
Medico-Chir.  Review,  Feb.,  '96). 

The  Spleen. — The  spleen  is  always  en- 
larged, although  in  varying  degree.  Its 
consistency  is  diminished,  often  to  such 
an  extent  that  the  attempt  to  remove  it 
results  in  rupture  of  its  tense  capsule  and. 
the  escape  of  its  diffluent  pulp.  The 
pulp  is  frequently  the  seat  of  a  melanosis 
varying  in  intensity  from  a  dark-brown 
to  almost  a  deep-black  discoloration;  it 
is  sometimes  evenly  distributed  over  the 
entire  organ  and  sometimes  irregularly 
deposited.  The  cut  surface  is  usually 
a  dark-gray-brown  or  slaty  color,  and 
the  unpigmenteel  Malpighian  corpuscles 
stand  out  prominently.  The  capsule  is 
thin  and  easily  torn.  Microscopically, 
dilatation  of  the  venous  sinuses,  often 
marked,  is  to  be  observed.  The  pulp 
contains  enormous  numbers  of  red  blood- 
corpuscles,  which  in  greater  part  are 
found  to  be  infected  with  parasites  in  all 
stages  of  development,  while  occasionally 
free  parasites  are  to  be  found. 

The  presence  of  large  numbers  of 
phagocytes,  particularly  the  large  cells 
known  as  macrophages  previously  re- 
ferred to,  is  a  marked  characteristic. 
While  leucocytic  phagocytes  occur,  the 
predominating  variety  is  this  large  cell, 
which  exists  in  very  considerable  num- 


496 


MALARIAL  FEVERS.    PATHOLOGICAL  ANATOMY. 


bers.  The  protoplasm  of  these  cells  is 
seen  to  contain  pigment-granules,  in 
clumps  or  rods,  as  well  as  parasites  free 
or  included  within  their  corpuscular 
hosts.  The  parasites,  which  are  in  vari- 
ous stages  of  development,  often  com- 
plete their  cycle  of  existence  while  thus 
contained  within  the  macrophages,  and 
the  latter  not  infrequently  show  evi- 
dences of  necrosis;  a  probable  result  of 
the  destructive  effect  of  the  parasite. 
The  splenic  veins,  while  containing 
phagocytes  laden  with  pigment,  contain 
comparatively  few  infected  blood-cor- 
puscles; with  the  latter,  however,  the 
capillaries  are  usually  filled. 

Capillary  thrombosis  may  be  the  cause 
of  necrotic  foci  scattered  throughout  the 
structure  of  the  spleen.  The  spleen  in 
all  cases  does  not  present  marked  mela- 
nosis, and  in  many  cases  is  relatively  free 
from  both  pigment  and  parasites. 

The  Liver. — In  most  cases  the  liver  is 
somewhat  enlarged  and,  from  the  large 
number  of  parasites  and  pigment  con- 
tained within  its  capillaries,  is  of  a  dark- 
slate-colored  hue,  often  almost  black. 
Microscopically,  the  capillaries  of  the 
hepatic  artery,  of  the  portal  vein,  and 
of  the  hepatic  vein  are  found  to  be 
crowded  with  pigmented  parasites.  In 
the  branches  of  the  portal  vein  may  be 
seen  the  very  largest  macrophages,  which 
have  originated  in  the  spleen  and  which, 
on  account  of  their  large  size,  obstruct 
the  calibre  of  the  vessels.  The  hepatic 
cells  are  swelled  and  often  contain  pig- 
ment, and  at  times  fragments  of  red  I 
blood-corpuscles  may  be  observed  within 
them.  The  capillary  endothelial  cells 
not  infrequently  show  the  presence  of 
pigment  as  an  evidence  of  their  phago- 
cytic action,  and  as  they  are  often  con- 
siderably swelled  the  capillary  lumen  be- 
comes correspondingly  limited.  In  the 
periportal  connective  tissue  a  small-cell  . 


proliferation  is  not  infrequently  to  be  ob- 
served, which  may  be  the  starting-point 
from  which  occurs  the  hepatic  cirrhosis 
at  times  noted  as  a  sequel  to  malarial 
infection  (Mannaberg). 

[Barker  (Johns  Hopkins  Hosp.  Re- 
ports, vol.  v,  '95)  describes  the  occurrence 
of  scattered  foci  of  local  necrosis  of  the 
liver-tissue,  depending,  probably,  upon 
capillary  thrombosis  brought  about  by 
various  forms  of  leucocytes.  They  are 
very  similar,  however,  to  analogous 
changes  occurring  in  other  acute  infec- 
tious diseases,  in  which  their  occurrence 
is  ascribed  to  the  action  of  circulating 
toxins.  James  C.  Wilson  and  Thomas 
G.  Ashton.] 

The  liver  in  most  cases  shows  a  varying 
degree  of  hyperemia,  which  accounts,  to 
a  certain  extent,  for  the  enlargement  of 
this  organ.  To  the  hyperemia,  also,  as 
well  as  to  the  large  amount  of  pigment 
deposited  in  the  organ,  is  to  be  ascribed 
its  increase  in  weight. 

The  Kidneys. —  The  macroscopical 
changes  so  apparent  in  the  liver  and 
spleen  are  not  often  to  be  observed  in 
the  kidneys.  Nevertheless,  at  times, 
points  of  pigmentation  can  be  detected 
within  the  cortex  or  along  the  course  of 
the  vessels  in  the  pyramids.  Microscop- 
ically, pigmentation  io  a  considerable  ex- 
tent may  be  observed,  especially  in  the 
glomeruli,  the  pigment  being  contained 
within  large  leucocytes,  which  may  pro- 
duce a  narrowing  of  the  calibre  of  the 
vessels;  at  times  the  endothelium  of  the 
glomeruli  may  be  pigmented.  Degenera- 
tion and  desquamation  of  the  epithelium 
of  the  capsules  of  Bowman  constitute  one 
of  the  most  serious  lesions,  while  in  the 
tubules  may  be  found,  here  and  there, 
areas  of  necrotic  epithelium. 

In  hsemofflobimiric,  or  black-water, 
fever  the  changes  in  the  kidneys  are  most 
marked.  They  are  usually  increased  in 
size,  of  somewhat  lessened  consistence, 


MALARIAL  FEVERS.    PATHOLOGICAL  ANATOMY. 


497 


and  of  varying  color,  being  frequently 
pale  and  anaemic  in  appearance;  less  fre- 
quently they  are  a  darkened  color.  Upon 
the  surface  of  the  organ,  especially  when 
it  is  pale,  are  to  be  observed  scattered 
brownish  spots  due  to  pigment-deposits 
which  crowd  the  epithelium  and  lumina 
of  the  uriniferous  tubules.  Kiener  and 
Kelsch  (Arch,  de  Phys.  Norm,  et  Path., 
'92)  have  also  described  the  appearance 
of  intratubular  haemorrhages  within  the 
pyramids,  as  a  result  of  which  this  por- 
tion of  the  renal  structure  assumes  a 
deep-red  color.  Microscopically  the  renal 
epithelium  is  found  to  contain  pigment; 
and  pigment-rodlets,  or  fine-yellow  gran- 
ules, or  dark,  amorphous  masses,  are  ob- 
served to  fill  the  lumina  of  the  urinifer- 
ous tubules.  Usually  some  of  the  tubes 
are  filled  with  blood-corpuscles,  and 
sometimes  the  evidences  of  a  beginning 
nephritis  are  found. 

The  G astro-Intestinal  Tract. —  Except 
in  a  few  instances,  the  gastro-intestinal 
tract  shows  but  little  change  other  than 
that  arising  from  the  deposit  of  pigment. 
Microscopically  the  capillaries  of  the 
mucous  membrane  may  be  found  to  con- 
tain parasites  as  well  as  phagocytic  cells 
containing  pigment  in  greater  or  less 
amount. 

It  has  been  shown  by  Bignami,  however, 
that  in  certain  instances  the  gastro-intes- 
tinal tract  may  constitute  the  point  of 
chief  localization  of  the  infecting  para- 
sites. These  cases,  clinically,  usually  pre- 
sent the  manifestations  characteristic  of 
the  choleraic  form  of  pernicious  fever. 
Microscopically  there  may  be  intense  in- 
jection of  the  mucous  membrane  of  the 
stomach  and  intestines,  with  numerous 
punctiform  haemorrhages:  The  capil- 
laries of  the  mucous  membrane  may  be 
crowded  and  their  lumina  obstructed 
with  parasites,  which  may  be  contained 
within    phagocytes,   or   red  blood-cor- 

4- 


puscles,  or  may  exist  free.  These  throm- 
boses result  in  necrosis  of  the  epithelium 
of  the  mucous  membrane  with  super- 
ficial ulceration.  Barker  (Johns  Hop- 
kins Hosp.  Eeports,  vol.  v,  '90)  reports  a 
case  in  which  the  capillaries  of  the  mu- 
cous membrane  were  so  blocked  with 
parasites  contained  within  mononuclear 
macrophages  that  numerous  small,  cir- 
cumscribed areas  of  necrosis  of  the  mu- 
cosa resulted. 

The  Lungs. — In  many  cases  areas  of 
broncho-pneumonia  or  infarction  are  to 
be  observed,  and  it  is  somewhat  note- 
worthy that  the  areas  of  broncho-pneu- 
monia do  not,  as  a  rule,  show  the  presence 
of  pigment.  Microscopically  the  capil- 
laries of  the  alveoli  are  found  to  be  filled 
with  infected  blood-corpuscles  and  ma- 
crophages. 

The  capillary  endothelium  infre- 
quently contains  pigment,  although  the 
large  number  of  phagocytes  contained 
within  the  alveolar  capillaries  may  lead 
to  necrosis.  It  is  unusual  to  find  pig- 
ment-containing leucocytes  in  the  in- 
terior of  the  alveoli. 

The  Heart  and  Muscles. — The  cardiac 
muscle  is  frequently  pale,  softened  in 
consistence,  and  shows  the  evidences  of 
fatty  degeneration;  the  same  changes 
may  be  observed  in  the  general  muscular 
system.  This  degeneration  of  the  myo- 
cardium and  of  the  voluntary  muscles 
may  in  part  be  due  to  the  blocking  up 
of  the  capillaries  with  parasite-contain- 
ing blood-corpuscles  and  cells. 

Literature  of  '96-'97-'98. 

Many  authors  believe  that  malaria 
may  cause  definite  heart-lesions,  but 
again  there  is  not  a  single  case  reported 
which  is  of  convincing  evidence,  and  as 
negative  proof  against  this  theory  La- 
veran  and  the  other  authorities  on 
malaria  hold  the  opposite  view.  Norton 
(Amer.  -lour.  Med.  Sci.,  Feb.,  '98). 

32 


498. 


MALARIAL  FEVERS.    PATHOLOGICAL  ANATOMY. 


The  Bone-marrow. — The  bone-marrow 
is  of  brown-red  color,  sometimes  almost 
black;  it  is  soft,  almost  diffluent.  The 
vessels  are  found  to  contain  developing, 
as  well  as  sporulating,  parasites,  and 
crescents  are  usually  present  in  abun- 
dance. About  the  periphery  of  the  lu- 
mina  of  the  vessels  macrophages  contain- 
ing pigment  may  be  found  in  consider- 
able numbers.  Nucleated  red  blood- 
corpuscles,  which  sometimes  exist  in 
great  numbers,  do  not  contain  parasites 
(Mannaberg). 

The  Brain. — Macroscopically  the  brain 
may  show  but  slight  evidence  of  change, 
and  melanosis  may  not  be  present.  Usu- 
ally, however,  a  distinct  localization  of 
the  infected  blood-corpuscles  appears  to 
take  place  in  the  cerebral  capillaries,  and 
then  melanotic  discoloration,  especially 
of  the  gray  matter,  may  be  observed. 
Marked  discoloration  of  the  cortex  may 
thus  occur,  with  deep  injection  of  the 
blood-vessels  and,  not  infrequently, 
numerous  punctiform  haemorrhages. 
These  changes  are  to  be  particularly  ob- 
served in  instances  of  pernicious  fever  of 
the  comatose  form,  and  in  such  cases  the 
microscopical  findings  are  remarkable. 
Parasites  in  all  stages  of  development, 
although  one  stage  usually  predomi- 
nates, crowd  the  cerebral  capillaries  un- 
til, in  places,  complete  obstruction  or 
thrombosis  of  their  lumina  takes  place. 
These  parasites,  although  commonly  seen 
to  be  within  red  blood-corpuscles,  may  be 
free,  or  contained,  together  with  pigment 
or  Mood-corpuscles,  within  phagocytes. 
The  latter  may  be  macrophages,  leuco- 
cytes, or  may  be  derived  from  the  endo- 
thelium of  the  capillaries. 

Chronic  Malarial  Infections  and 
Chronic  Malarial  Cachexia.  —  Nu- 
merous pathological  changes  are  to  be 
observed  in  the  organs  of  those  who  have 
been  the  subjects  of  long-continued  in- 


fection with  malaria;  the  most  note- 
worthy of  these  changes  occur  in  the 
spleen,  liver,  and  bone-marrow. 

The  Spleen. — Notable  enlargement  of 
the  spleen  always  occurs,  and  thickening 
of  its  capsule  is  usually  to  be  found.  This 
thickening,  as  a  rule,  is  not  evenly  dis- 
tributed, but  is  apt  to  show  as  scattered 
islets.  Not  infrequently  these  islets,  or 
plaques,  are  cartilaginous  in  character, 
and  occasionally  ossification  of  the  cap- 
sule takes  place.  The  consistence  of  the 
enlarged  spleen  is  much  increased  and  its 
border  is  usually  well  defined.  Its  color 
is  usually  red,  but  not  infrequently  it 
has  a  grayish-brown  or  slaty  color.  The 
cut  surface  shows  marked  prominence  of 
the  trabecular,  which  corresponds  to  the 
degree  of  increase  of  the  connective  tis- 
sue and  thickening  of  the  sheaths  of  the 
vessels.  The  veins  are  dilated  to  such 
an  extent  as  to  simulate  angiomata,  and 
the  Malpighian  bodies  are  but  slightly 
apparent. 

The  microscopical  changes  are  signifi- 
cant. Shortly  after  the  termination  of 
the  actual  infection  a  cessation  of  the 
acute  hyperemia  occurs  and  necrotic 
areas  develop  in  the  pulp,  while  some  of 
the  follicles  also  become  necrotic  and 
fibrous.  In  addition,  extensive  regener- 
ative changes  take  place,  originating 
largely  from  the  follicles,  which  become 
markedly  hyperplastic;  hyperplasia  of 
the  elements  of  the  pulp  is  also  to  be  ob- 
served. The  arrangement  of  the  pigment 
becomes  changed;  it  gathers  in  small 
clumps  in  the  pulp  and  becomes  con- 
centrated in  the  sheaths  of  the  vessels 
and  the  connective  tissue  of  the  septa. 
The  macrophages,  which  in  the  acute 
tumor  are  the  carriers  of  the  pigment, 
disappear,  probably  as  the  result  of  de- 
generation, and  the  pigment  in  the 
chronic  tnmor  becomes  extracellular 
(Mannaberg).     Subsequently   the  pig- 


MALARIAL  FEVERS.    PATHOLOGICAL  ANATOMY. 


499 


ment  disappears  completely.  While  ab- 
sorption of  the  areas  of  necrosis  takes 
place,  dilatation  of  the  vessels  and  hyper- 
trophy of  the  septa  become  more  marked 
and  the  splenic  pulp  becomes  so  com- 
pressed as  to  entirely  disappear.  The 
final  result  of  these  changes  is  that  the 
function  of  the  spleen  is  entirely  de- 
stroyed and  the  recognition  of  its  histo- 
logical elements  becomes  impossible. 

The  Liver. — The  liver  is  increased  in 
volume  and  weight,  at  times  very  greatly; 
its  surface  is  smooth  and  its  consistence 
increased;  thickening  of  the  capsule  is 
of  frequent  occurrence.  The  cut  surface 
is  found  to  vary  somewhat  in  accordance 
with  the  duration  of  the  infection.  In 
general,  the  lobules  are  slightly  promi- 
nent and  quite  distinct,  while  the  appear- 
ance of  the  surface  is  finely  granular. 

The  changes  to  be  observed  by  micro- 
scopical examination  are  thus  summa- 
rized by  Mannaberg  from  the  researches 
of  Bignami.  Shortly  after  the  termina- 
tion of  the  acute  infection  it  will  be  no- 
ticed that  the  parasites  have  disappeared 
from  the  capillaries,  the  endovascular 
macrophages  are  no  longer  to  be  seen, 
and  the  pigment  is  entirely  collected  in 
the  endothelium  and  in  Kupffer's  cells. 
A  decided  atrophy  occurs  in  those  parts 
of  the  liver-lobules  in  which  necrosis  has 
taken  place  and  the  vessels  become  di- 
lated. The  lobule  is  further  freed  from 
pigment,  which  is  carried  by  the  mono- 
nuclear and  polymorphonuclear  leuco- 
cytes to  its  periphery.  At  the  same  time 
the  beginning  of  regenerative  changes 
becomes  apparent  in  the  liver-cells. 

The  next  stage  is  that  which,  in  conse- 
quence of  the  atrophic  and  regenerative 
processes,  leads,  on  the  one  hand,  to  the 
development  of  pseudo-angiomata  and 
lymphatic  cysts,  and,  on  the  other,  to 
the  formation  of  abnormally-large  lob- 
ules.   The  pigment  is  carried  out  of  the 


vessels  by  the  leucocytes  and  deposited  in 
the  perivascular  lymph-spaces,  while  the 
perilobular  connective  tissue  becomes 
hyperplastic. 

The  final  result  is  a  large,  dense  liver, 
of  a  reddish  color,  which  upon  section 
shows  the  finely-granular  lobules  to  be 
surrounded  by  trabecular  of  connective 
tissue.  The  vessels  are  dilated  and  the 
organ  is  congested,  while  pigmentation 
is  no  longer  to  be  seen.  Kelsch  and 
Kiener  assert  that  a  few  months  after 
the  termination  of  the  acute  infection 
pigment  is  no  longer  to  be  found,  and 
Bignami  has  observed  that  it  has,  in 
large  part,  disappeared  in  from  three  to 
four  months. 

The  development  of  a  true  atrophic 
cirrhosis  of  the  liver  due  to  malarial  in- 
fection is  as  yet  an  undecided  question, 
and  must  be,  in  any  event,  of  rare  occur- 
rence. Kelsch  and  Kiener,  however,  dis- 
tinguish three  forms  of  chronic  malarial 
hepatitis  ([1]  with  hyperemia;  [2]  with 
cirrhosis;  [3]  with  adenomata)  and  two 
groups  of  cirrhosis  ([1]  insular  cirrhosis 
with  nodular  hepatitis,  and  insular  cir- 
rhosis with  diffuse  parenchymatous  hepa- 
titis; [2]  annular  cirrhosis,  with  nodular 
or  diffuse  parenchymatous  hepatitis). 

Both  Marchiafava  and  Bignami  deny 
that  true  cirrhosis  follows  malaria,  and 
make  the  following  distinctions:  In  the 
case  of  malarial  cirrhosis  or  hepatitis  the 
increase  in  the  connective  tissue  is  peri- 
lobular, and  surrounds  the  individual 
lobules,  and  the  branches  of  the  portal 
veins  are  not  obliterated.  In  true  at- 
rophic cirrhosis  the  hyperplastic  con- 
nective tissue  surrounds  a  number  of 
lobules,  retracts  upon  them,  and  leads  to 
compression  of  the  portal  vessels.  The 
changes  taking  place  in  the  liver-cells  in 
the  two  conditions  are  also  different,  be- 
ing, as  the  result  of  malaria,  of  a  grave 
nature  and  primarily  local,  while  in  true 


MALARIAL  FEVERS.  DIAGNOSIS. 


500 

atrophic  cirrhosis  they  depend  upon  the 
newly-formed  perilobular  connective  tis- 
sue. 

The  Bone-marrow.  —  The  marrow  of 
the  long  ones,  particularly  in  the  upper 
and  lower  portions,  is  usually  red  and  its 
consistence  somewhat  increased.  The 
microscopical  examination  reveals  pro- 
liferation, more  or  less  active,  of  the  cel- 
lular elements  of  the  marrow,  and  greatly 
increased  vascularity.  The  mononuclear 
myelocytes,  both  large  and  small,  are  in- 
creased and  many  of  them  show  evidences 
of  degeneration.  Nucleated  red  blood- 
cells,  or  normoblasts,  are  found  in  large 
numbers,  as  well  as  a  few  megaloblasts 
or  gigantoblasts.  Pigment  disappears 
from  the  bone-marrowT  much  earlier  than 
from  the  other  organs.  In  rare  cases  the 
marrow  presents  the  same  features  as  is 
found  in  pernicious  anaemia,  showing  a 
considerable  number  of  gigantoblasts 
and  megaloblasts. 

The  Kidneys. — No  marked  changes  oc- 
cur in  the  kidneys  in  chronic  malaria. 
Kelsch  and  Kiener,  however,  describe 
two  forms  of  kidney  occasionally  met 
with  in  this  condition:  the  congested 
form  and  the  atrophic  form.  The  histo- 
logical changes  characterizing  these  con- 
ditions seem  hardly  called  for  in  the  scope 
of  the  present  article. 

Diagnosis. — The  diagnosis  of  malarial 
fevers  mainly  depends  upon  the  result  of 
the  examination  of  the  blood,  and  the 
more  doubtful  the  case,  the  more  it  re- 
sembles some  other  affection,  the  more 
necessary  is  a  resort  to  this  means  of 
attaining  a  positive  conclusion.  To  a 
less  degree  the  diagnosis  is  established  by 
the  results  of  the  therapeutic  test:  i.e., 
the  administration  of  quinine  and  the 
clinical  manifestations. 

In  many  cases  the  symptom-grouping, 
the  regularly-recurring  paroxysms,  and 
the  orderly  sequence  with  which  the  | 


various  stages  succeed  one  another  may 
be  quite  sufficiently  characteristic  to 
warrant  the  diagnosis  of  malaria.  This 
is  particularly  true  if  the  case  be  one  of 
single  tertian,  single  quartan,  or  double 
quartan  infection,  for  no  disease  through 
any  considerable  period  of  time  will  pre- 
sent such  regularity  in  the  recurrence  of 
the  febrile  paroxysms.  There  are  many 
affections  frequently  encountered,  how- 
ever, which  offer  some  difficulty  in  dif- 
ferentiating from  malarial  fever  of  quo- 
tidian type  whether  due  to  double  ter- 
tian or  triple  quartan  infection. 

Pulmonary  tuberculosis — from  its 
wide  prevalence  and  the  fact  that  it  is  fre- 
quently attended  by  daily  febrile  parox- 
ysms consisting  of  more  or  less  well-de- 
fined stages  of  chill,  fever,  and  sweating 
— is  probably  more  commonly  mistaken 
for  malaria,  in  regions  where  the  latter 
affection  prevails,  than  any  other  disease. 
Only  ignorance  or  carelessness,  on  the 
part  of  the  physician,  however,  can  re- 
sult in  confusing  the  two  maladies.  In 
tuberculosis  the  absence  of  splenic  en- 
largement, the  amemia's  lacking  the 
peculiar  sallowness  of  malaria:  the  oc- 
currence of  the  febrile  paroxysm  in  the 
later  hours  of  the  afternoon  instead  of 
the  forenoon,  except  when  the  inverse 
type  of  fever  prevails;  the  result  of  the 
physical  exnmination  of  the  lungs,  the 
presence  of  tubercle  bacilli  in  the  spu- 
tum, and  the  result  of  the  blood-ex- 
amination constitute  a  group  of  events 
which,  when  properly  interpreted,  pre- 
clude the  possibility  of  confusion  be- 
tween these  two  diseases. 

Other  septic  processes  may  be  con- 
fused with  malarial  fever,  such  as  the 
fever  accompanying  malignant  endo- 
carditis; septic  processes  involving  the 
biliary  passages  or  the  genito-urinary 
organs,  as  pyelitis,  pyelonephritis,  or 
urethral   fever,  so  called,  arising  from 


MALARIAL  FEVERS.  DIAGNOSIS. 


501 


gonorrhoea  or  the  introduction  of  instru- 
ments into  this  passage;  the  fever  asso- 
ciated with  malignant  new  growths,  or 
empyemata  in  various  locations.  In  all 
these  instances  the  previous  history  of 
the  case,  the  results  of  the  physical  ex- 
amination and  the  examination  of  the 
"blood  will  decide  the  diagnosis.  Of 
these,  of  course,  the  most  important  is 
the  blood-examination;  the  absence  of 
leucocytosis,  or  actual  reduction  of  the 
number  of  leucocytes,  and  the  presence 
of  parasites  in  malaria;  the  presence  of 
leucocytosis  and  absence  of  parasites  in 
the  various  forms  of  septicaemia. 

The  aastivo-autumnal  fevers  may  also 
be  confused  with  tuberculosis  and  other 
septic  processes  particularly  in  those  in- 
stances where  the  intervals  between  the 
paroxysms  are  well  marked.  The  same 
means  of  differentiation  are  to  be  in- 
voked, however,  as  in  the  case  of  the 
regularly-intermittent  fevers.  When  by 
retardation  and  anticipation  of  the  par- 
oxysms, however,  the  intervals  between 
them  become  almost  or  completely  oblit- 
erated, aastivo-autumnal  fever  may  so  re- 
semble typhoid  fever  that  an  examina- 
tion of  the  blood  becomes  necessary  to 
establish  the  diagnosis.  Here  the  pres- 
ence or  absence  of  the  parasites  must 
alone  be  depended  upon,  as  in  neither 
disease  does  leucocytosis  occur.  Clin- 
ically the  persistence  of  a  trace  of  the 
paroxysm,  the  presence  of  jaundice,  early 
anamiia,  herpes  or  urticaria,  and  the  rela- 
tive  infrequency  of  Ehrlich's  diazo-reac- 
tion  in  the  urine  will  aid  in  confirming 
a  diagnosis  of  malaria. 

Four  undoubted  instances  in  which  the 
co-existence  of  malaria  and  typhoid  has 
been  actually  proved  by  microscopical 
blood-examinations.  These  at  least  are 
all  that  it  has  been  possible  to  find  on 
record. 

Other  than  irregularity  of  fever,  and 
occasionally  chills,  there  is  nothing  in 


these  cases  of  mixed  infection  by  which 
to  suspect  their  nature,  and  the  course 
of  the  typhoid  malady  is  not  influenced; 
it  only  proves  how  necessary  it  is  in  all 
instances  of  typhoid  fever,  especially  of 
the  irregular  kinds,  to  make  blood-exami- 
nations for  malarial  parasites.  J.  M.  Da 
Costa  (Internat.  Clinics,  vol.  ii,  Seventh 
Series). 

The   PERNICIOUS  FORMS   OF  MALARIA 

are  to  be  separated  from  conditions  with 
which  they  are  likely  to  be  confounded 
chiefly  by  an  examination  of  the  blood. 
In  these  forms  confusion  may  arise  be- 
tween the  hgemorrhagic  type  and  yellow 
fever,  the  choleriform  type  and  Asiatic 
cholera,  the  comatose  type  and  insola- 
tion, and  the  hsemoglobinuric  type  and 
ordinary  paroxysmal  haemoglobinuria. 
To  the  observer  the  examination  of  the 
blood  may  constitute  the  only  positive 
means  of  reaching  a  definite  conclusion. 

Chronic  malarial  cachexia  is  to  be  dif- 
ferentiated from  the  grave  anaemias,  leu- 
kaemia, and  pseudoleukemia  by  the  ex- 
amination of  the  blood,  or,  when  this 
fails  to  give  positive  results,  by  the  early 
history  of  the  patient  and  the  amena- 
bility of  the  condition  to  proper  remedial 
measures. 

The  administration  of  quinine  is  the 
therapeutic  test  for  malaria,  and  is  of 
importance  if  it  be  impossible  to  make 
a  microscopical  examination  of  the  blood. 
Under  the  influence  of  proper  doses  of 
this  drug  no  malarial  fever  will  persist 
for  more  than  four  or  five  days. 

Literature  of  '96-'97-'98. 

Neglect  of  examinations  of  blood  has 
led  to  the  gravest  mistakes.  A  patient 
presented  herself  to  a  surgeon,  complain- 
ing of  pain  in  the  lower  abdomen,  pelvis, 
and  back,  with  chills  and  fever.  Upon 
examination  a  mild  pelvic  peritonitis  was 
found.  She  was  advised  to  have  the  tubes 
and  ovaries  removed,  and  submitted  to 
the  operation.  The  patient  had  a  severe 
chill  the  next  day.  followed  by  a  rise  of 


502 


MALARIAL  FEVERS.    COMPLICATIONS  AND  SEQUELAE. 


temperature  to  107°,  and  collapse.  The 
blood  was  then  examined  and  found  teem- 
ing with  malarial  organisms.  The  patient 
eventually  recovered,  out  nevertheless 
the  operator  was  negligent  in  not  exclud- 
ing by  systematic  study  of  the  case  the 
possibility  of  malarial  infection,  before 
performing  what  proved  to  be  an  unneces- 
sary mutilating  operation.  W.  W.  Rus- 
sell (Johns  Hopkins  Hosp.  Bull.,  Nov. 
and  Dec,  '96). 

Cases  of  malaria  illustrating  its  vari- 
ous manifestations.  One  commenced  with 
symptoms  of  catarrhal  dysentery  without 
chill  or  variation  of  temperature,  the 
symptoms  exhibiting  periodic  exacerba- 
tion. In  another  case  there  was  severe 
diarrhoea,  with  two  days'  intermission 
and  considerable  malaise;  in  another  di- 
arrhoea of  three  weeks'  duration.  A  case 
of  ulcerative  stomatitis  was  cured  on 
three  occasions  with  quinine.  Other  cases 
presented  urticaria,  conjunctivitis,  leg- 
ulcers,  periodic  pains  in  the  knee,  Bell's 
palsy  with  periodic  fever,  paralysis  of  the 
extensor  muscles  of  the  right  hand,  with 
the  development  ultimately  of  typical  in- 
termittent fever.  In  all  of  these  cases 
but  one  the  malarial  parasite  was  found 
in  the  blood,  sometimes  only  after  re- 
peated examinations,  and  quinine  caused 
prompt  recovery.  R.  A.  Goodner  (Med. 
News.,  Dec.  17,  '98). 

Complications  and  Sequelae.  —  Com- 
plications are,  in  great  part,  the  result 
of  mixed  infections  with  other  morbific 
agents,  and  comparatively  few  are  due 
to  the  direct  action  of  the  malarial  toxin, 
although  some  may  arise  from  causes 
that  are  purely  mechanical. 

The  Lungs.  —  Croupous  pneumonia 
and  broncho-pneumonia  may  occur  as 
true  complications  of  malaria,  and  are 
then,  of  course,  to  be  considered  as  due 
to  secondary  infections,  and  not  as  a  re- 
sult of  the  specific  malarial  toxin.  The 
latter  may  render  the  person  more  sus- 
ceptible to  pneumococcic  infection  by 
impairing  the  general  resistance,  but  no 
more  intimate  relation  exists  between 
the  two  diseases.    Of  course,  the  condi- 


tions already  described  as  associated  with 
the  pneumonic  form  of  pernicious  fever 
in  all  probability  depend  upon  the  local- 
ization of  the  parasite  in  the  pulmonary 
blood-vessels  and  are  therefore  directly 
due  to  the  malarial  infection;  but  this 
is  not  a  true  pneumonia  and  is  unaccom- 
panied by  the  signs  of  consolidation. 

The  association  of  pleurisy  and  mala- 
ria may  occur  and,  as  with  pneumonia, 
is  to  be  regarded  as  purely  accidental  and 
in  no  wise  a  consequence  of  the  original 
infective  process. 

Tuberculosis. — The  malarial  subject  is 
equally  as  liable  to  pulmonary  tuberculo- 
sis as  the  non-malarial.  This  is  con- 
trary to  the  views  held  by  early  observers, 
who,  following  the  lead  of  Boudin  (Traite 
des  Fievres  Intermittentes,  Paris,  '±2), 
adopted  the  view  that  the  two  infections 
were  in  some  manner  incompatible  with 
each  other.  As  a  matter  of  fact,  in  warm 
climates  where  malaria  prevails  its  asso- 
ciation with  tuberculosis  is  uncommon 
because  the  climatic  conditions  are  such 
as  limit  the  occurrence  of  this  infection, 
and  in  regions  where  tuberculosis  pre- 
vails malaria,  as  a  rule,  is  infrequent. 
To  climatic  conditions,  therefore,  rather 
than  to  any  antagonism  between  the  two 
infections  is  to  be  ascribed  their  rela- 
tively infrequent  association  in  the  same 
subject. 

Typhoid  Fever.  —  The  relations  be- 
tween typhoid  fever  and  malaria  are  the 
same  as  between  malaria  and  other  in- 
fective processes.  From  our  present 
knowledge  of  malarial  fever  and  the  aid 
in  diagnosis  afforded  by  the  microscope 
we  know  that  there  is  no  distinct  clin- 
ical type  of  the  disease  to  which  the 
term  typho-malaria  may  be  properly  ap- 
plied. The  class  of  cases,  the  continued 
forms  of  a?stivo-autumnal  fevers,  which 
have  been  the  source  of  so  much  con- 
fusion respecting  the  two  infections,  have 


MALARIAL  FEVERS.    COMPLICATIONS  AND  SEQUELAE. 


503 


already  been  referred  to.  The  examina- 
tion of  the  blood  in  these  cases  and  the 
action  of  quinine  afford  means  of  diag- 
nosis as  easy  of  application  as  they  are 
decisive  in  results.  An  acute  malarial 
infection  or  the  lighting  up  of  an  old 
one  may  occur  in  the  course  of  typhoid 
infection,  and  the  symptoms  of  the  latter 
may  be  so  modified  as  to  indicate  the 
character  of  the  complication,  but  the 
two  infections  complete  their  course  in- 
dependently of  each  other  and  their  as- 
sociation does  not  give  rise  to  a  new 
clinical  or  pathological  entity. 

Infections  other  than  typhoid  fever, 
such  as  the  eruptive  fevers,  acute  rheu- 
matism, and  the  like,  bear  the  same  rela- 
tion to  malaria. 

Chkonic  Malarial  Cachexia. — As 
the  result  of  neglected  cases  of  malarial 
fever,  usually  of  the  gestivo-autumnal 
variety,  or  as  the  result  of  inadequate 
treatment  by  quinine,  a  series  of  relapses 
occur  which  eventually  give  rise  to  such 
impairment  of  the  general  health  as  to 
establish  a  chronic  cachexia.  This  is  the 
most  frequently  met  with  sequel  to  mala- 
rial fever  and  first  manifests  itself  as  an 
anaemia,  which,  if  the  cause  be  not  re- 
moved, may  develop  to  the  gravest  pro- 
portions. The  patient's  appearance  be- 
comes distinctive,  and,  with  the  evidences 
of  profound  anaemia,  the  skin  presents 
a  sallow  or  muddy  color;  the  mucous 
membranes  are  all  but  colorless,  while 
the  extreme  exhaustion,  breathlessness 
upon  the  slightest  exertion,  headache, 
and  subcutaneous  oedema  indicate  the 
gravity  of  the  changes  that  have  occurred 
in  the  blood.  Digestive  disturbances  are 
common  and  the  tongue  is  frequently 
coated.  Great  enlargement  of  the  spleen, 
the  most  pronounced  that  may  be  en- 
countered, occurs  in  this  condition,  giv- 
ing rise  to  the  popular  term  of  "ague- 
cake."     Neuralgia,    especially   of  the 


supraorbital  and  intercostal  nerves,  is  a 
common  incident  and  the  occurrence  of 
vertigo  upon  any  sudden  change  of  posi- 
tion may  interfere  with  the  patient's  lo- 
comotion. In  advanced  cases  dropsical 
effusions  into  the  serous  cavities  may 
take  place,  while  marked  emaciation,  ex- 
haustive diarrhoea,  anorexia,  and  pro- 
found asthenia  render  the  patient  par- 
ticularly susceptible  in  intercurrent  in- 
fections. 

Chronic  malarial  cachexia  may  pursue 
throughout  an  afebrile  course  or  it  may 
be  punctuated  by  irregularly-recurring 
paroxysms  of  mild  pyrexia;  in  still  other 
instances  an  irregular,  subfebrile  tem- 
perature may  exist  for  a  long  period. 
While  any  variety  of  malarial  infection 
may  be  followed  by  cachexia,  it  usually 
occurs  as  a  sequel  to  the  aestivo-au- 
tumnal.  The  blood-examination  may  be 
negative.  In  aestivo-autumnal  infections, 
however,  crescents  and  ovoid  bodies  are 
nearly  always  found,  while  in  other  in- 
fections pigmented  leucocytes  and  a  few 
parasites  are  usually  to  be  seen. 

Relapses.  —  This  sequel  has  already 
been  referred  to  as  arising  from  the  fail- 
ure to  pursue  treatment  sufficiently  to 
destroy  all  the  parasites  at  the  period  of 
sporulation,  so  that  the  parasites  thus 
escaping  continue  to  pass  through  suc- 
cessive cycles  of  development  until  a 
group  is  produced  of  sufficient  size  to 
cause  the  toxic  manifestations  consti- 
tuting a  paroxysm.  There  are  other  in- 
stances, however,  in  which  the  relapse 
takes  place  a  long  time  after  the  termina- 
tion of  the  original  paroxysm,  and  such 
instances  have  been  ascribed  to  the  per- 
sistence of  some  form  of  the  parasite 
within  some  of  the  internal  organs. 

Anjemia. — In  addition  to  the  changes 
in  the  blood  indicative  of  secondary 
anaemia  of  a  grave  type,  in  certain  in- 
stances the  alterations  characteristic  of 


504 


MALARIAL  FEVERS. 


COMPLICATIONS  AND  SEQUELAE. 


PROGNOSIS. 


progressive  pernicious  anaemia  occur;  the 
termination  of  such  cases  is,  of  course, 
a  fatal  one. 

Hepatic  Sequels. — The  malarial  in- 
fection is  undoubtedly  the  basis  for 
hepatic  changes  in  a  certain  number  of 
cases.  These  changes  have  already  been 
referred  to,  and  as  they  are  usually  un- 
accompanied by  clinical  manifestations, 
further  reference  to  them  need  not  be 
made. 

Nephritis.  —  Some  involvement  of 
the  kidneys  usually  occurs  in  very  grave 
malarial  infection.  Nephritis  in  its  most 
intense  forms  is  to  be  found  in  associa- 
tion with  malarial  hsemoglobinuria,  and, 
as  already  stated,  may  then  prove  rapidly 
fatal.  In  ordinary  cases,  however,  re- 
covery ensues  without  permanent  dam- 
age to  the  organs. 

Amyloid  Degeneration.  —  Amyloid 
degeneration  is  of  infrequent  occurrence 
as  a  sequel  to  malaria.  Of  the  145  cases 
of  amyloid  degeneration  in  the  Collective 
Statistics  of  Fehr  only  4  could  be  as- 
cribed to  malarial  infection;  and  of  43 
cases  reported  by  Eosenheim  only  4  fol- 
lowed this  infection  (Mannaberg). 

Mental  disturbances,  disorders  of 
the  special  senses,  peripheral  neuritis, 
cerebral  and  spinal  paralyses  may  occur 
as  post-malarial  manifestations.  As  a 
rule,  their  tendency  is  toward  complete 
recovery. 

Literature  of  '96-'97-'98. 

Six  cases  of  paralysis  of  the  bladder  oc- 
curring in  the  course  of  malarial  affec- 
tions. Patients  were  all  men,  and  mostly 
those  past  middle  life.  Sometimes  the 
paralysis  came  on  in  the  course  of  ma- 
larial fever;  in  other  instances  it  was  the 
first  symptom  of  malarial  infection.  Once 
it  had  appeared,  it  did  not  subside  until 
the  malarial  trouble  was  entirely  cured, 
and  then  it  disappeared  as  suddenly  as  it 
had  set  in.  Marion  (N.  Y.  Med.  .lour.: 
Medical  Bull.,  Dec,  '97). 

Death  caused  by  urinary  suppression 


in  malarial  hematinuria  in  90  per  cent, 
of  all  cases.  Vogel  (Indian  Lancet,  Nov. 
1,  '97). 

Two  cases  of  aphasia  due  to  malaria. 
The  treatment  and  the  result  showed  the 
correctness  of  diagnosis.  Somapa  S. 
Lingayet  (Indian  Lancet,  Jan.  10,  '97). 

Retinal  lesions  found  in  the  graver 
forms  of  malarial  poisoning:  swelled  ar- 
teries and  veins,  perivascular  oedema,  and 
sometimes  swelling  of  the  papilla  itself. 
In  the  blood  of  the  retinal  vessels  were 
found  the  well-known  changes  in  the  red 
blood-corpuscles  characteristic  of  malaria. 
Guarnieri  (Arch,  per  la  Sci.  Med.,  No.  1, 
'97). 

All  malarial  lesions  of  the  eye  originate 
in  circulatory  troubles.  They  are  under 
the  classified  head:  (1)  neuritis;  (2) 
retinal  haemorrhages;  (3)  retinochoroi- 
ditis;  (4)  effusions  into  the  vitreous. 
Certain  obscure  affections  noted  are  sud- 
den and  persistent  amaurosis,  without 
visible  fundus-change,  periodical  amauro- 
sis, sudden  amaurosis  ending  in  atrophy, 
persistent  central  scotoma,  and  periodical 
blue  vision.  T.  M.  Yarr  (Brit.  Med.  Jour., 
Sept.  24,  '98). 

Diagnosis  between  quinine  and  malarial 
amblyopia  can  only  be  made  by  an  ex- 
amination of  the  fundus  of  the  eye.  By 
this  method  retinal  alterations  are  found 
like  those  observed  in  patients  suffering 
from  malarial  disease,  or  simply  ischsemic 
troubles,  as  in  cases  of  quinine  intoxica- 
tion. It  is  very  rare  that  amaurosis  due 
to  malaria  shows  a  tendency  to  remain 
and  becomes  permanent,  while  quinine 
amblyopia,  even  when  it  is  not  perma- 
nent, persists  for  a  considerable  time. 
Ischsemia  of  the  disk  constitutes  the  true 
pathognomonic  sign  of  cinchonic  intoxi- 
cation. If  nerve-atrophy  is  accompanied 
by  marked  contraction  of  the  retinal  ves- 
sels, and  the  ocular  trouble  has  immedi- 
ately followed  the  malarial  manifesta- 
tions which  call  for  necessary  energetic 
quinine  medication,  the  patient  is  snivel- 
ing from  quinine  amaurosis.  .luan 
Santos  (X.  Y.  Med.  Jour..  May  14.  '98). 

Prognosis. — The  prognosis  of  malaria 
is  influenced  by  a  number  of  conditions 
the  most  important  of  which  is  the 
variety  of  parasite  to  which  infection 


MALARIAL  FEVERS.    PROGNOSIS.  TREATMENT. 


505 


may  be  clue.  Thus,  the  prognosis  of  or- 
dinary quartan  and  tertian  fevers  when 
properly  treated  is  almost  always  favor- 
able, although  even  these  milder  forms 
of  infection,  if  treatment  be  neglected  or 
inefficiently  carried  out,  may  be  followed 
by  cachexia  or  anaemia  of  severe  grade. 
As  already  mentioned,  however,  the  tend- 
ency in  these  infections  is  toward  spon- 
taneous recovery.  iEstivo-autumnal  in- 
fections, on  the  other  hand,  show  this 
tendency  to  a  much  less  degree,  and  if 
left  to  themselves  are  much  more  likely 
to  pass  on  into  one  of  the  grave  post- 
malarial  conditions,  or  to  develop  per- 
nicious manifestations;  nevertheless  the 
prognosis  of  ordinary  aestivo-autumnal 
fevers,  when  properly  treated,  is  favor- 
able, although  it  must  be  borne  in  mind 
that  in  this  infection  greater  activity  of 
treatment  is  demanded. 

In  the  pernicious  fevers  the  prognosis 
is  always  grave  and  can  never  be  consid- 
ered as  favorable  until  that  period  of 
time  has  passed  during  which  the  occur- 
rence of  a  second  paroxysm  is  likely. 
These  cases,  of  course,  call  for  the  great- 
est activity  in  treatment,  and  upon  the 
efficiency  with  which  this  is  carried  out 
the  prognosis  largely  depends. 

The  grave  anaemias  occurring  as  se- 
quelae of  malaria  are  events  which  should 
cause  the  deepest  concern  regarding  ulti- 
mate recovery;  their  course  is  only  too 
apt  to  show  progressive  tendencies.  The 
prognosis  of  chronic  malarial  cachexia 
depends  largely  upon  the  patient's  ability 
and  willingness  to  take  advantage  of 
changed  climatic  conditions. 

Literature  of  '96-'97-'98. 

Malaria  is  a  disease  thai  rarely  kills  in 
the  large  towns  of  the  Atlantie  sea-board. 
William  Osier  (Internat.  Med.  Mag..  Jan.. 
'96). 

Five  thousand  and  forty-four  cases  of 
malaria  collected  from  the  records  of  five 


I  hospitals  in  Philadelphia  and  it  is  found 

that  there  has  been  a  decline  in  the  num- 
ber of  cases  during  the  last  half-century 
and  more  especially  during  the  last 
twenty-five  years.  J.  M.  Anders  (Univ. 
Med.  Mag.,  May,  '97). 

Treatment. — In  cinchona  and  its  de- 
rivatives, more  particularly  quinine,  we 

I  possess  a  remedy  against  malaria  that 

I  may  be  regarded  as  a  true  specific.  That 
quinine  owes  its  efficacy  in  malaria  to 
the  destructive  influence  which  it  exerts 
upon  the  parasite  is  now  agreed  to  by 
all  observers.  The  changes  in  the  para- 
site resulting  from  its  administration 
have  been  given  close  study  by  Laveran, 
Golgi,  Eomanowsky,  Marchiafava,  Big- 
nami,  Mannaberg,  and  others.  The  ac- 
tion is  most  marked  upon  the  young  ex- 
tracorpuscular  bodies  and  very  slight 

I  upon  the  parasite  during  the  corpuscular 
phase  of  its  existence.  This  is  true  not 
only  of  the  parasites  of  the  regularly  in- 
termittent group  of  fevers,  but  is  also 
true  of  the  parasite  of  aestivo-autumnal 
fever.  It  follows,  therefore,  that  the  ad- 
ministration of  quinine  a  few  hours  be- 
fore an  expected  paroxysm  will  not  pre- 
vent its  occurrence,  because  at  the  time 
of  its  administration  the  parasites  being 
within  the  corpuscles  are  in  that  phase 
of  their  cycle  of  existence  during  which 
they  are  the  least  susceptible  to  the  ac- 
tion of  the  drug.  Segmentation  is  not 
prevented,  therefore,  and  the  paroxysm 
occurs,  but  the  resulting  free  young  seg- 
ments are  destroyed  and  their  further 
evolution  cut  short,  so  that  the  next  suc- 
ceeding paroxysm  is  averted. 

After  the  administration  of  quinine 
the  active  movements  of  the  amoeboid 
parasite,  particularly  of  the  tertian  vari- 
ety, are  observed  to  lessen,  while  the  pig- 
ment tends  to  clump  and  the  parasite 
becomes  more  highly  refractive.  At  the 
same  time  the  parasites  are  much  dimin- 

I  ished  in  number  and  present  the  evi- 


506 


MALARIAL  FEVERS.  TREATMENT. 


dences  of  degeneration,  hydropic  and 
fragmented  forms  prevailing. 

The  mode  of  administering  quinine  is 
to  be  regulated  in  accordance  with  the 
exigencies  of  the  case.  In  the  milder 
forms  of  infection  its  administration  by 
the  mouth  is  the  preferable  mode,  while 
in  cases  of  severe  grade,  where  quick 
action  of  the  specific  is  all-important, 
and  in  cases  in  which  the  drug  induces 
vomiting,  its  hypodermic  administration 
is  demanded.  By  the  mouth  quinine  is 
best  given  in  solution,  notwithstanding 
its  bitter  taste,  as  in  this  form  only  will 
its  prompt  absorption  be  absolutely  as- 
sured. If  given  in  capsule,  or  as  the 
much-resorted-to  quinine  pill,  at  best  the 
absorption  of  the  drug  is  delayed  and  at 
the  worst  may  be  passed  off  by  the  bowel 
within  the  undissolved  capsule  or  pill- 
coating.  Under  certain  circumstances  it 
may  be  deemed  advisable  to  give  quinine 
in  the  form  of  rectal  enemata;  this  is 
the  least  certain  of  all  the  methods  of 
administering  the  drug,  however,  and 
should  only  be  employed  when  for  some 
reason  its  administration  by  one  of  the 
other  methods  is  contra-indicated. 

Tablets  of  quinine  frequently  pass  di- 
gestive tract  without  being  absorbed; 
neutral  tannate  of  quinine  for  prolonged 
use.   Aufrecht  (Ther.  Monats.,  July,  '95). 

[I  heartily  concur  with  Aufrecht,  that 
quinine  should  never  be  given  in  the  form 
of  tablets.  The  ordinary  pill  of  quinine — 
especially  when  sugar-coated  or  gelatin- 
coated — I  have  frequently  discovered  in 
the  alvine  discharges  unchanged.  I  con- 
sider the  bichloride  of  quinine  the  best 
and  most  soluble  form.  It  may  be  given 
in  freshly-made  gelatin  capsules,  but  the 
cachets  of  the  French — concave,  paper- 
like disks  made  of  rice-flour — are  the 
best.  Judson  Daland,  Assoc.  Ed.,  An- 
nual, '96.] 

Literature  of  '96-'97-'98. 

In  children  quinine  bisulphate  is  move 
efficacious  than  the  sulphate.   Two  grains 


are  given  as  the  child  is  years  in  age,  or 
as  many  milligrammes  (V50  grain)  as  the 
child  is  months  old.  In  children  under 
two  months,  instead  of  internal  use  of 
quinine,  friction  with  a  pomade  of  30 
grains  of  quinine  bisulphate  to  1  1/2 
ounces  of  axungum  is  ordered  to  be 
rubbed  under  the  arms  and  in  the  groins. 
In  nurslings  of  three  to  eight  months 
three  suppositories  a  day  may  be  used, 
the  dose  of  quinine  being  twice  as  great 
as  by  the  mouth.  If  tenesmus  of  rectum 
is  provoked,  enemata  of  quinine — three 
a  day — should  be  used.  Feuchtwanger 
(Med.  and  Surg.  Rep.,  Jan.  30,  '97). 

The  choice,  of  the  particular  salt  of 
quinine  to  be  given  is  a  matter  of  some 
importance,  as  they  are  found  to  differ 
widely  in  the  degree  of  their  solubility 
and  the  percentage  of  the  alkaloid  which 
they  contain.  Although  but  very  slightly 
soluble  in  water,  the  sulphate  of  quinine 
is  the  form  most  commonly  employed. 
It  is,  however,  readily  soluble  in  acid 
solutions;  so  that  when  given  in  water 
it  is  customary  to  add  sufficient  sulphuric 
acid  to  effect  its  solution. 

Literature  of  '96-'97-'98. 

Quinine  is  a  specific  for  all  forms  of 
malarial  infection.  W.  S.  Thayer  (X.  Y. 
Med.  Jour.,  Nov.  20,  '97). 

Fifteen  grains  of  quinine  with  15  grains 
of  powdered  ginger  twice  a  day.  and 
three  doses  of  1/2  ounce  of  camphorated 
tincture  of  opium  given  in  47  cases  of 
malaria.  Twenty-two  were  cured  at 
once,  5  within  24  hours:  10  within  4S 
hours,  and  12  of  the  remaining  15  at 
later  periods;  3  were  not  benefited.  No 
relapse  occurred  in  any  case.  The  para- 
site found  in  most  of  these  cases  was  of 
the  aestivo-autumnal  type.  In  6  cases 
there  was  mixed  infection  with  typhoid 
and  malaria:  4  of  these  got  well  of  the 
malaria  during  the  course  of  the  typhoid, 
and  in  2  the  malaria  reappeared  after 
convalescence  from  the  typhoid  fever. 
W.  H.  Thompson  (Med.  News,  Dec.  17, 
'98). 

Quinine  is  a  poison  to  the  plasmodium, 


MALARIAL  FEVERS.  TREATMENT. 


507 


but  is  useless  against  the  toxin  manu- 
factured by  the  latter.  The  destruction 
of  haemoglobin  of  red  cells  by  malarial 
parasite  aids  in  thermolysis,  and  this  de- 
fect can  be  compensated  by  administer- 
ing such  remedies  as  tend  to  increase 
amount  of  haemoglobin  in  blood,  at  same 
time  combining  with  it  such  antiperiodic 
as  quinine.  L.  H.  Warner  (N.  Y.  Med. 
Jour.,  Dec.  10,  '98). 

The  susceptibility  to  quinine  exhibited 
by  some  persons  can  be  nearly  always 
overcome  by  giving  quinine  with  hydro- 
bromic  acid  or  the  bromides — for  ex- 
ample, twice  as  much  bromide  of  sodium 
as  quinine.  Muriate  of  quinine  favored 
instead  of  the  sulphate.  Andrew  H. 
Smith  (Med.  Rec,  Jan.  15,  '98). 

When  administered  hypodermically 
the  neutral  hydrochlorate  of  quinine  is 
to  be  preferred  on  account  of  its  greater 
solubility,  1  part  being  soluble  in  0.66 
parts  of  water.  The  following  solution 
is  recommended  by  de  Beurmann  and 
Yillejean  for  this  purpose: — 

I£  Quinine  dihydrochlorate,  75  grains. 
Distilled  water,  enough  to  make 
2  V2  drachms.— M. 

One  cubic  centimetre  (15  minims)  of 
this  solution  represents  0.50  (8  grains) 
of  quinine  dihydrochlorate.  (Laveran.) 

The  intravenous  injection  of  quinine 
has  been  advocated  by  Baccelli,  but,  as 
pointed  out  by  Laveran,  it  should  not 
be  resorted  to  "except  in  the  very  severe 
pernicious  paroxysms  and  when  there  is 
reason  to  fear  that  even  the  hypodermic 
method  will  not  effect  a  sufficiently- 
rapid  introduction  of  the  salts  of  quinine 
into  the  blood."  Baccelli  recommends 
the  following  solution: — 

J£  Quinine  hydrochlorate,  15  grains. 
Sodium  chloride,  12  grains. 
Distilled  water,  2  1/2  fluidounces. 
— M. 

This  solution  is,  of  course,  to  be  in- 
jected warm. 


For  certain  pernicious  forms  of  malaria 
the  intravenous  injection  of  a  neutral 
salt  of  quinine  should  be  given:  — 

R<  Quinine  hydrochloratis,  15  grains. 
Sodii  chloridi,  1  grain. 
Aquse  destill.,  2  V2  drachms. — M. 

This  may  be  injected  into  the  veins 
in  progressively-diminishing  doses.  Bac- 
celli (Wiener  med.  Woch.,  Jan.  11,  '90). 

The  administration  of  quinine  should 
be  so  timed  that  the  maximum  influence 
of  the  drug  shall  be  obtained  at  the  time 
of  the  sporulation  of  the  parasites,  for 
the  reason,  as  has  just  been  said,  that 
it  exerts  but  little  toxic  influence  upon 
the  parasites  as  long  as  they  remain 
within  the  blood-corpuscles.  The  drug 
is  given,  therefore,  not  with  the  hope  of 
averting  the  pending  paroxysm,  but 
with  the  purpose  of  destroying  the  free 
young  segments  upon  which  the  succeed- 
ing paroxysms  will  depend.  In  the 
fevers  of  the  regularly  intermittent 
variety  this  object  is  readily  accom- 
plished, and  even  small  doses  of  the  drug 
will  frequently  prove  quite  sufficient.  It 
is  well,  however,  to  vary  the  dose  some- 
what in  accordance  with  the  severity  of 
the  case  even  in  this  type  of  fever;  so 
that,  while  in  the  milder  cases  2  grains 
given  three  times  daily  will  prove  ef- 
fective in  breaking  up  the  paroxysms,  in 
the  cases  of  a  somewhat  more  severe  in- 
fection it  may  be  well  to  give  5  grains 
three  times  daily.  It  is  at  times  ad- 
visable in  this  latter  class  of  cases  to 
give  a  large  dose  of  quinine  at  the  ex- 
pected time  of  the  paroxysm,  and,  after 
having  thus  for  several  days  prevented 
its  occurrence,  to  continue  the  use  of  the 
drug  in  small  doses  three  times  daily  for 
several  weeks.  It  is  claimed  by  Laveran 
that  the  type  of  fever  should  not  cause 
any  very  marked  variation  in  the  manner 
of  the  administration  of  quinine,  either 
as  regards  the  dosage  or  the  time  of  tak- 


508  MALARIAL  FEVERS.  TREATMENT. 


ing.  Thus,  for  a  male  adult  he  advises  I 
the  following  practical  directions:  "On 
the  1st,  2d,  and  3d  days  from  80  centi- 
grammes to  1  gramme  (12  to  15  grains) 
of  quinine  hydrochlorate  daily  in  the 
course  of  twenty-four  hours;  on  the  4th, 
5th,  6th,  and  7th  days  no  quinine;  on 
the  8th,  9th,  and  10th  days  from  60  to 
80  centigrammes  (9  to  12  grains)  of 
quinine  hydrochlorate;  from  the  11th  to 
the  14th  day  no  quinine;  on  the  15th 
and  16th  days  from  60  to  80  centi- 
grammes (9  to  12  grains)  of  quinine  hy- 
drochlorate; from  the  17th  to  the  20th 
days  no  quinine;  on  the  21st  and  22d 
days  from  60  to  80  centigrammes  (9  to 
12  grains)  of  quinine  hydrochlorate." 

Literature  of  '96-'97-'98. 

Segmentation  occurs  at  or  about  the 
time  of  the  paroxysm  ;  hence  the  quinine 
should  be  given  shortly  before  it  in  order 
that  it  may  be  in  solution  in  the  blood 
when  segmentation  takes  place.  In  this 
way  a  group  of  organisms  may  be  almost 
entirely  destroyed  by  a  single  dose.  It 
is  advisable  to  give  a  second  dose  just  be- 
fore the  time  at  which  the  next  paroxysm 
would  occur.  Fifteen  or  20  grains  may 
be  given  for  the  first  dose  and  10  grains 
for  the  second.  J.  L.  Morse  (Boston  Med. 
and  Surg.  Jour.,  Jan.  16,  '96). 

In  order  to  suppress  attack  of  typical 
intermittent  an  adult  is  to  be  given  25 
grains  of  quinine.  In  cases  of  masked 
malaria  it  may  become  necessary  to  in- 
crease the  dose,  even  up  to  50  grains. 
Quinine  is  to  be  given,  at  the  very  least, 
six  hours  before  the  ensuing  attack.  J. 
Ballagi  (Indian  Lancet,  Dec.  16,  '97). 

In  tropical  malaria  the  usual  blind  ad- 
ministration of  quinine  at  regular  inter- 
vals is  absolutely  useless.  Quinine  dot  s 
not  kill  the  plasmodium ;  it  merely 
•  hecks  its  development.  To  produce  the 
desired  effect,  it  should  be  administered 
in  the  stage  in  the  development  of  the 
Plasmodium  that  precedes  sporulation. 
Quinine  at  the  right  moment  cures  trop- 
ical malaria  in  its  worst  forms.  R.  Koch 
(Hot  Springs  Med.  Jour..  Aug.,  '98). 


In  the  aestivo-autumnal  fevers  treat- 
ment should  be  more  actively  pursued 
and  larger  doses  of  quinine  employed. 
Owing  to  the  irregularity  in  time  with 
which  the  parasites  undergo  segmenta- 
tion quinine  should  be  given  irrespective 
of  the  occurrence  of  the  paroxysm,  so 
that  its  administration  may  be  com- 
menced in  doses  of  5  grains  every  four 
hours  as  soon  as  the  case  comes  under 
observation.  If  the  case  be  very  severe 
and  pernicious  manifestations  feared, 
several  larger  doses  of  the  drug  (15 
grains)  may  be  given  at  intervals  of  a 
few  hours  either  hypodermic-ally  or  by 
intravenous  injection,  while  subsequently 
its  use  may  be  continued  in  smaller 
doses.  If  pernicious  symptoms  have  al- 
ready occurred,  no  chances  that  the  drug 
may  be  absorbed  through  the  stomach 
should  be  taken;  it  is  imperative  under 
these  circumstances  to  administer  it  un- 
der those  conditions  most  favorable  to  its 
rapid  absorption;  that  is,  by  hypodermic 
or  intravenous  injection  after  the  method 
of  Baccelli. 

Literature  of  '96-'97-'98. 

In  pernicious  malaria  cinchonism 
should  be  produced  as  rapidly  as  pos- 
sible, and.,  since  the  temperature-varia- 
tions are  exceedingly  irregular,  large 
doses  are  necessary.  The  stomach  will 
rarely  accept  the  necessary  doses,  and 
hypodermic  and  intravenous  injections 
(Baccelli's  method)  are  to  be  considered. 
Great  depression  should  be  combated  1»\ 
strychnine  and  digitalis,  and  patient 
sustained  by  enemas  of  whisky,  pepto- 
nized foods,  and  broths.  Clarence  J. 
Manly  (Ther.  Gaz.,  Dec,  '97). 

Notwithstanding  the  fact  that  quinine 
is  held  by  some  observers  to  be  directly 
responsible  for  the  hemorrhagic  phe- 
nomena characterizing  malarial  haemo- 
globinuria.  no  particular  modification  of 
the  treatment  should  be  made  in  the 
management  of  these  cases.    In  a  gen- 


MALARIAL  FEVERS.    TREATMENT.  5Q9 


eral  way,  the  same  treatment  that  is  ap- 
plicable to  the  other  forms  of  pernicious 
fever  is  to  be  employed  in  malarial 
hemoglobinuria . 

Literature  of  '96-'97-'98. 

In  treatment  of  hemoglobinuria  in 
malaria  persulphate  of  iron  and  inhala- 
tions of  oxygen  are  the  most  useful.  If 
the  malarial  attack  necessitates  quinine 
its  continuance  is  advised  even  in  spite 
of  hsemoglobinuria.  Baccelli  (II  Poli- 
clinico,  Jan.  15,  '97). 

Quinine  objected  to  in  malarial  hsema- 
turia,  and  following  treatment  recom- 
mended: 1.  Sodium  hyposulphite  in 
drachm  doses  every  two  hours  until  the 
patient  is  thoroughly  purged;  continued 
in  smaller  doses  until  the  system  is  satu- 
rated with  it.  Free  sulphurous  acid  is 
disengaged  in  the  blood,  and  this  agent 
is  an  antizymotic  to  such  an  extent  that 
it  destroys  the  micro-organisms  that  are 
the  real  cause  of  the  disease,  and  thus 
arrests  the  process  of  corpuscular  disin- 
tegration. 2.  Morphine  and  atropine 
hypodermically,  sufficient  to  quiet  the 
stomach;  and  blisters  over  the  epigas- 
trium, if  necessary.  3.  An  abundance  of 
water  to  wash  out  the  coagula  that  must 
necessarily  accumulate  in  the  urinary 
tubules  after  a  haemorrhage.  Hot  water 
or  hot  lemonade  is  frequently  better 
borne  by  the  stomach  than  cold.  Cup- 
ping over  the  loins  is  also  to  be  recom- 
mended. 4.  A  mild  diet;  fresh  butter- 
milk is  usually  well  borne.  5.  The  pa- 
tient should  remain  in  a  strictly  recum- 
bent position.  Meek  (Ther.  Gaz.,  May 
15,  '97). 

Quinine  should  not  be  given  in  ma- 
larial hematuria.  The  injudicious  ad- 
ministration of  quinine  is  often  respon- 
sible for  an  haematuric  attack.  M. 
Coltman  and  William  Krauss  (Memphis 
Lancet,  Dec,  '98). 

Tyson  recommends  quinine  in  malarial 
hematuria  and  believes  that  this  symp- 
tom is  due  to  another  cause  than  quinine. 
Alberl  Woldert  (Med.  News,  Apr.  30, 
'98). 

Quinine  acts  nearly  as  a  specific  in  all 
malarial  fevers  characterized  by  inter- 
missions or  well-marked  remissions,  but 


fails  in  continued  fevers,  those  with 
typhoid-like  symptoms,  those  malarial 
conditions  without  high  temperature, 
and  the  cachexias  and  ansemias  due  to 
malaria. 

Quinine  should  never  be  used  in  hsemo- 
globinuria, or  given  subsequently  to  one 
who  has  suffered  from  it.  J.  S.  Van 
Marter,  Jr.  (N.  C.  Med.  Jour.;  Louis- 
ville Med.  Monthly,  Sept.,  '98). 

In  the  management  of  chronic  mala- 
rial cachexia  much  often  depends  upon 
the  ability  or  willingness  of  the  patient 
to  remove  to  a  non-malarious  and  healthy 
climate.  Indeed,  in  some  instances  the 
adoption  of  such  a  course  is  absolutely 
necessary  to  effect  a  cure.  At  the  same 
time  quinine  in  small  doses  should  be 
taken  for  a  long  time  to  destroy  the  para- 
sites remaining  in  the  blood  and  organs, 
and  measures  should  be  adopted  to  over- 
come the  profound  asthenia  and  anaemia. 
The  indications  of  the  former  are  usu- 
ally fully  met  by  the  administration  of 
bitter  tonics  and  an  abundant  and  nutri- 
tious diet,  while  the  latter  usually  calls 
j  for  the  use  of  arsenic;  indeed,  in  this 
condition  a  long-continued  treatment 
with  arsenic  in  ascending  doses  often 
proves  most  effective;  not  only  is  this 
remedy  of  value  in  the  treatment  of  the 
anaemia  incident  to  chronic  malarial 
cachexia,  but  it  is  also  to  be  employed 
in  the  same  manner  to  combat  the  anae- 
mia that  is  of  such  common  occurrence 
during  the  convalescence  from  the  acute 
forms  of  infection. 

Literature  of  ,d6-'97-'9$. 

Four  cases  of  malarial  cachexia  treated 
with  the  spleen  and  bone-marrow  of 
cattle,  with  apparently  favorable  results. 
Gritzmann  (Allg.  Wien.  med.  Zeit.,  June 
30,  '90). 

Of  5  cases  of  malarial  cachexia  lien  ted 
with  hypodermic  injections  of  citrate  of 
iron,  four  cases  recovered  completely. 
The  fifth  was  greatly  improved.  Naame 
(Rev.  de  Med.  de  Paris,  Mar.  10,  '97). 


510  MALARIAL  FEVERS.  TREATMENT. 


Certain  symptoms  arising  during  the 
course  of  a  malarial  paroxysm  may  call 
for  special  treatment,  but  the  indications 
to  be  met  are  only  those  to  which  gen- 
eral principles  may  be  applied  and  hardly 
seem  to  call  for  particular  mention. 

Various  substitutes  for  quinine  in  the 
treatment  of  malaria  have  been  advo- 
cated, including  the  other  derivatives  of 
cinchona,  methylene-blue,  arsenic,  strych- 
nine, iodine,  and  a  number  of  others. 
All  of  these,  however,  are  far  inferior  to 
quinine  in  their  antimalarial  action,  and, 
with  the  exception  of  arsenic  under  the 
conditions  already  mentioned,  possess  a 
very  limited  applicability. 

In  children  hydrobromate  of  quinine  of 
service  in  same  doses  as  other  salts  of  the 
alkaloid.  Especially  useful  in  nervous, 
excitable  children.  Solubility  further 
promoted  by  association  with  antipyrine. 
Comby  (La  Med.  Mod.,  Aug.  28,  '95). 

Successful  employment  of  methylene- 
blue.  Seven  and  one-half  grains  were 
given  six  hours  in  advance  of  the  time  of 
the  expected  attack,  and,  subsequently, 
1 1/2  grains  or  more  five  times  daily. 
Guttmann  and  Ehrlich  (Wiener  med. 
Woch.,  Oct.  24,  '91). 

Methylene  -  blue  unsuccessfully  em- 
ployed in  five  cases,  in  hourly  doses  of 
1.5  grains  five  or  six  times,  as  many 
hours  in  anticipation  of  the  paroxysm. 
While  it  appeared  to  control  the  parox- 
ysm, it  did  not  prevent  recurrence.  Its 
use  was  also  attended  with  irritability 
of  the  gastro-intestinal  and  genito-uri- 
nary  tracts.  Ketli  (Ungarisches  Archiv 
f.  Med.,  B.  2,  H.  1,  '93). 

Methylene-blue  employed  in  thirty-five 
cases  of  intense  malarial  fever:  the  drug 
exercises  an  influence  upon  the  Plas- 
modia, as  these  were  found  to  disappear 
and  the  paroxysms  not  to  recur.  The 
remedy  was  administered  internally,  or 
injected  subcutaneously.  The  injections 
were  given  twice  daily,  15  grains  of  from 
a  1-per-cent.  to  a  5-per-cent.  solution  of 
methylene-blue  being  used  on  each  occa- 
sion. The  paroxysms  did  not  recur  after 
from  three  to  five  injections  had  been 


given.  By  the  mouth  capsules  contain- 
ing 6  to  7.5  grains  were  given  twice  or 
thrice  daily.  Unpleasant  symptoms, 
such  as  headache,  anorexia,  and  vomit- 
ing, were  in  some  cases  observed  to  occur 
after  internal  administration.  Porenski 
and  Blatteis  (Ther.  Monats.,  Jan..  '93). 

Upward  of  forty  cases  in  children 
treated  with  methylene-blue,  with  en- 
tirely satisfactory  results.  Dose  em- 
ployed varied  from  4  to  7  V2  grains  in  the 
course  of  twenty-four  hours,  according 
to  the  age  of  the  patient  and  the  severity 
of  the  attack.  The  drug  was  of  especial 
value  in  protracted  and  obstinate  cases 
that  resisted  treatment  by  other  means, 
and  in  cases  of  intermittent  and  remit- 
tent not  sufficiently  severe  to  be  of  im- 
mediate danger  to  life.  In  pernicious 
cases  it  would  be  judicious  to  join  the 
subcutaneous  injections  of  quinine  bihy- 
drochlorate.  Its  administration  should 
be  continued  for  several  days  after  the 
subsidence  of  the  fever  and  the  disap- 
pearance of  the  other  symptoms.  It  may 
be  given  in  solution  in  syrup  of  orange- 
peel  and  syrup  of  canella.  To  larger 
children  it  may  be  administered  in  tab- 
let, cachet,  or  capsule.  Ferreira  (Bull. 
Gen.  de  Ther.,  June  15,  '93). 

Living  malarial  parasites  subjected, 
under  the  microscope,  to  the  action  of  a 
solution  of  quinine  1  to  5000,  and  of  a 
solution  of  methylene-blue  1  to  20.000. 
The  former  did  not  at  all  affect  the  move- 
ment of  the  plasmodia,  not  even  after  ten 
hours;  the  latter  destroyed  it  very  soon, 
and  in  about  half  an  hour  the  microbes 
were  stained  a  beautiful  blue.  H.  Rosin 
(Schmidt's  Jahrbiicher,  May  15,  '94). 

Of  2501  men  on  whom  arsenic  waa 
tried,  579  were  suffering  from  acute  and 
1384  from  chronic  malaria.  The  remain- 
ing 538  were  free  from  the  disease.  In 
the  acute  cases  arsenic  was  of  little  use, 
but  it  gave  excellent  results  in  t ho 
chronic  cases,  and  in  the  others  it  seemed 
to  confer  immunity,  or,  if  they  con- 
tracted the  affection,  it  was  of  a  mild 
type  and  easily  cured  with  quinine.  The 
men  put  on  flesh,  and  lost  the  pallid, 
cachectic  look  characteristic  of  dwellers 
in  malarial  regions.  Daily  administration 
of  arsenous  acid  increases  the  resistance 


MALARIAL  FEVERS. 


TREATMENT. 


511 


of  the  organism  to  the  action  of  the 
microbes  of  malaria.  Ricchi  (Brit.  Med. 
Jour.,  Apr.  27,  '89). 

Phenocoll  is  as  effective  as  quinine  in 
malarial-fever  state,  whereas  quinine,  in 
many  instances,  gives  rise  to  toxic  symp- 
toms. Phenocoll  has  not  been  found  to 
give  rise  to  such  unpleasant  effects. 
Phenocoll  succeeds  in  a  certain  number  of 
cases  in  which  quinine  absolutely  fails. 
The  taste  of  the  drug  can  easily  be 
masked  by  means  of  syrup,  and  is  not 
objected  to  even  by  children.  Dall  (Gaz- 
zetta  degli  Osp.,  Jan.  14,  '93). 

Phenocoll  should  be  substituted  in 
pregnant  women  suffering  from  malaria, 
this  drug  having  no  action  on  the  uterus ; 
in  doses  of  22  grains  divided  in  4  cachets, 
to  be  taken  5,  4,  3,  and  2  hours  before  a 
febrile  paroxysm  is  due.  Titone  (Rif. 
Med.,  Nov.  24,  '94). 

Nitrate  of  potassium  very  efficient  in 
the  treatment  of  chills  and  fever.  Sixty- 
five  per  cent,  of  personal  cases  cured  with 
a  single  dose;  35  per  cent,  were  uninflu- 
enced by  repeated  doses.  Best  results 
were  obtained  when  the  drug  was  admin- 
istered during  the  premonitory  stage,  in. 
anticipation  of  the  paroxysm.  Twenty- 
five  or  30  grains  at  this  period  will  abort 
the  attack  or  modify  its  course  and  in- 
tensity. Hunter  (N.  C.  Med.  Jour.,  Mar., 
'90). 

Sixty-one  children  were  treated  with 
helianthus,  in  the  form  either  of  an  alco- 
holic tincture  or  of  an  alcoholic  extract. 
Of  the  former,  from  XU  to  2  1/2  drachms 
were  given  daily  in  divided  doses  in  a 
potion,  and,  of  the  latter,  from  1/4  to  1 1/2 
drachms.  The  remedy  was  well  borne, 
even  by  the  youngest  infant.  In  the  ma- 
jority of  cases  the  cure  was  as  prompt  as 
with  quinine.  Methylene-blue  was  admin- 
istered to  30  children,  varying  in  age  from 
23  days  to  14  years.  A  cure  was  obtained 
in  10  cases,  amelioration  in  3,  while  in  14 
the  results  were  not  conclusive.  The 
drug  was  given  in  doses  of  from  3  1/i  to 
(i  grains  in  four  equal  parts,  in  the  course 
of  the  day.  The  medicament  was  well 
borne  and  only  in  1  case  caused  transient 
vesical  tenesmus.  Moncorvo  (Le  Bull. 
Med.,  Jan.  15,  '93). 


Literature  of  '96-'97-'98. 

Analgen  in  doses  of  4  to  15  grains  in 
twenty-four  hours  used  in  33  cases  of 
malaria  in  children  is  a  useful  adjuvant 
to  quinine,  and  a  substitute  when  the 
latter  cannot  be  administered.  Moncorvo 
(Bull,  de  l'Acad.  de  Med.,  Nov.  10,  '96). 

Guaiacol  used  in  the  treatment  of  ma- 
larial intermittent  fevers;  15  minims 
were  rubbed  into  the  axilla  and  covered 
with  cotton.  The  average  fall  of  tem- 
perature in  3/4  hour  was  1.6°,  in  1 3/4 
hours,  2.3°,  and  after  4  hours  the  aver- 
age fall  was  3°.  The  fall  of  temperature 
was  accompanied  by  a  free  perspiration 
and  a  marked  improvement  in  the  condi- 
tion and  comfort  of  the  patient.  No  de- 
pression was  noticed.  Rogers  (Ther. 
Gaz.,  May  15,  '96;  from  Indian  Med. 
Gaz.,  Jan.,  '96). 

Fifteen-minim  doses  of  creasote,  rubbed 
into  the  axilla  and  then  covered  with 
cotton-wool,  used  in  eight  cases  of  se- 
vere intermittent  fever  with  tempera- 
tures varying  from  103.2°  to  104.4°  F., 
the  temperature  being  either  stationary 
or  rising  at  the  time  the  drug  was  ap- 
plied. In  every  case  perspiration,  usually 
free,  was  produced  in  from  half  an  hour 
to  two  hours,  and  was  accompanied  by  a 
marked  fall  of  temperature,  averaging 
1.6°  F.  within  3/4  hour,  2.3°  after  1 3/4 
hours,  and  3°  within  4  hours  after  the 
use  of  the  drug.  At  the  same  time  all 
the  distressing  symptoms,  including  the 
severe  headache  always  present  with  high 
fever  in  these  cases,  were  decidedly  re- 
lieved. Leonard  Rogers  (Brit.  Med. 
Jour.,  Jan.  4,  '96). 

Roux's  serum  employed  in  2  cases  of 
quartan  fever.  In  the  first  there  were 
2  subsequent  rises  of  temperature  and 
then  complete  cure.  The  second  case, 
even  after  a  second  injection,  showed  no 
beneficial  result.  Treille  (Sem.  Med.  p. 
312,  '96). 

Seven  cases  of  malaria  treated  with 
methylene-blue  in  doses  of  1  l/2  grains, 
in  capsules,  given  six  or  eight  times  in 
the  day.  The  rapid  cessation  of  the  at- 
tack was  striking.  Microscopical  exami- 
nation showed  that  the  plasmodia  disap- 
peared from  the  blood  later  than  the 
febrile  attacks.  Duration  of  the  treat- 
ment extended  over  8  days  as  a  mini- 


MALARIAL  FEVERS.  PROPHYLAXIS. 


mum  and  23  days  as  maximum.  It  was 
determined  by  the  disappearance  of  the 
Plasmodia  and  of  the  splenic  enlarge- 
ment. Rottger  (Deut.  med.  Woch.,  Apr. 
9,  '96). 

Methylene-blue  should  only  be  used  in 
simple  intermittent  fevers,  and  it  would 
be  dangerous  to  substitute  it  for  quinine 
in  the  treatment  of  continued  fevers  and 
in  grave  cases.  It  is  only  indicated, 
when,  for  some  cause,  the  use  of  quinine 
is  contra-indicated,  especially  when,  even 
in  small  doses,  it  produces  hsemoglobi- 
nuria.  The  daily  dose  in  the  adult  is 
from  9  to  15  grains;  sometimes  it  pro- 
duces a  slight  cystitis  that  ceases  when 
the  drug  is  discontinued.  Cardamatis 
(Gaz.  des  Hop.,  Apr.  15,  '97). 

Phenocoll,  though  no  substitute  for 
quinine  as  an  antiperiodic  in  impaludism, 
has  valuable  analgesic  properties,  and  in 
small  doses  distributed  over  the  twenty- 
four  hours,  or  preferably  administered 
from  three  to  five  hours  before  the  access, 
alleviates  the  pains  of  the  ague-fit  and 
in  certain  cases  refractory  to  quinine  has 
even  shortened  its  duration.  However, 
Quirogne  has  found  that,  even  in  moder- 
ate doses,  phenocoll  has  the  disadvantage 
of  causing  symptoms  of  collapse.  Edi- 
torial (Sem.  Med.,  No.  54,  Nov.  17,  '97). 

Euchinin  is  superior  to  quinine  in  be- 
ing tasteless  and  requiring  a  smaller  dose 
to  reduce  temperature.  It  does  cause 
cinchonism.  In  from  10-  to  15-grain 
doses  it  is  equal  to  quinine  sulphate  in 
20-  to  30-grain  doses.  St.  George  Gray 
(Post-grad.,  May,  '98). 

In  those  cases  of  malaria  in  which 
there  is  an  idiosyncrasy  to  quinine,  sali- 
cin  and  sodium  salicylate  are  of  great 
advantage.  J.  R.  Gilbert  (Jour.  Amer. 
Med.  Assoc.,  Nov.  12,  '98). 

Myrrh  recommended,  in  the  treatment 
of  malaria,  in  the  following  formula: 
Quinine,  40  grains;  pulverized  myrrh, 
20  grains;  powdered  licorice,  10  grains. 
Forty  pills  arc  made,  one  of  which  is  to 
be  taken  every  two  hours.  The  myrrh 
increases  the  number  of  white  blood- 
corpuscles,  which  are  scavengers  of  the 
blood,  and  therefore  more  easily  elimi- 
nate the  malarial  plasmodium.  Aaron 
Jeffrey  (Med.  Rec,  Aug.  20.  '98). 

There  are  cases  of  chronic  intermittent 


fever,  with  large  tumefaction  of  the 
spleen,  that,  after  having  resisted  the 
action  of  quinine,  arsenic,  methylene- 
blue,  eucalyptus,  and  piperine,  are  bene- 
fited by  ergot.  Jacobi  (Med.  News,  Oct. 
22,  '98). 

In  the  treatment  of  mild  forms  of  ma- 
larial fever,  while  the  preparations  of 
bark  may  not  act  so  rapidly  as  quinine, 
they  are  often  more  efficacious.  After 
the  paroxysms  have  once  been  arrested 
they  are  not  so  apt  to  recur.  If  the  bark 
is  given  continuously  for  several  weeks 
the  patient's  general  condition  is  much 
better  than  it  is  in  those  cases  in  which 
quinine  in  small  or  moderate  doses  has 
been  persistently  taken.  B.  Robinson 
(Med.  Rec,  Jan.  15,  '98). 

Perfect  cure  in  cases  of  undoubted  ma- 
laria, which  had  proved  intractable  to 
quinine  in  large  doses  by  small  doses  of 
nuclein  (1  drop  every  two  or  three 
hours),  which  caused  a  prompt  disap- 
pearance of  the  cachexia,  migraine,  gas- 
trointestinal disturbances,  haematuria, 
general  depression,  and  other  so-called 
malarial  symptoms  under  which  the  pa- 
tients wrere  suffering.  Editorial  (Cincin- 
nati Lancet-Clinic,  Apr.  30,  '98). 

Prophylaxis.  —  General  measures  of 
prophylaxis  may  be  adopted  in  accord- 
ance with  the  facts  known  of  the  etiology 
of  the  infection  and  which  have  been 
referred  to  in  the  section  on  that  subject. 
Although  recent  researches  all  tend  to 
prove  that  infection  occurs  by  other 
channels  than  the  alimentary  tract, 
notably  the  skin,  it  is  the  part  of  pru- 
dence to  sterilize  by  boiling  water  com- 
ing from  infected  regions.  The  proph- 
ylactic value  of  quinine  is  not  to  be  over- 
looked, and  infection  may  often  be  pre- 
vented by  taking  the  drug  in  doses  of  6 
grains,  or  even  less,  in  the  twenty-four 
hours. 

To  reduce,  as  much  as  possible,  the 
quantity  of  the  malarial  ferment  that 
enters  into  the  system  through  the  air 
breathed  is  sought  to  be  achieved  by 
avoiding  agricultural  operations  during 
those  hours  at  which  the  malarious  in- 
fluence is  most  potent,  viz.:    about  sun- 


MALARIAL  FEVERS.  PROPHYLAXIS. 


513 


rise  and  sunset.  Another  point  of  the 
greatest  importance  is  to  avoid  breathing 
the  air  in  close  contact  with  the  soil,  as 
the  malarious  poison  rises  only  a  short 
distance  in  a  vertical  direction.  It  is  ad- 
visable to  keep  the  windows  closed  in  the 
morning  and  during  the  early  hours  of 
the  evening,  especially  if  any  excavation 
should  be  going  on  in  the  neighborhood. 
Flowers  should  be  entirely  excluded  from 
houses  when  malaria  is  rife,  or  the 
utmost  vigilance  should  be  taken  to  se- 
cure thorough  ventilation.  Tommasi- 
Crudeli  ("Climate  of  Rome  and  Roman 
Campagna,"  '92). 

Valerianate  of  quinine  as  a  prophylac- 
tic tried  under  strict  surveillance  in 
markedly  malarious  region.  Of  30  sol- 
diers 23  given  the  drug  regularly;  the 
7  untreated  suffered  from  fever,  those 
treated  remained  entirely  free.  L.  Cen- 
dero  (Boletino  de  Med.  Naval,  Aug.,  '95). 

Literature  of  '96-'97-'98. 

Conclusions  of  a  recent  treatise  on 
prophylaxis  of  malaria  are:  1.  To  ad- 
minister quinine  in  preventive  doses, 
12  to  15  grains,  at  intervals  of  four  or 
five  days,  is  considered  sufficient.  2.  As 
the  germs  are  in  the  atmosphere  and  are 
breathed  into  the  lungs,  troops  must  be 
commanded  to  keep  their  mouths  shut 
when  marching,  as  breathing  air  filtered 
through  the  nose  is  much  less  dangerous. 
3.  Malarial  districts,  marshes,  etc.,  must 
be  avoided  and  habitations  located  200 
to  300  metres  above  them  where  possible. 
No  work  should  be  permitted  in  the  heat 
of  the  day.  Houses  should  be  sur- 
rounded with  trees  at  least  their  own 
height,  and  w  indows  should  be  glazed  to 
keep  out  the  evening  dew.  Exposure  to 
ilii-  dew  must  be  strictly  avoided  as  far 
as  possible.  4.  Europeans  must  not  at- 
tempt to  cultivate  the  ground  in  the  in- 
tertropical regions.  It  is  death  to  them, 
but  does  not  injure  negroes  or  other  na- 
tives, who  should  he  secured  for  this 
purpose.  Maurel  (Bull.  Acad,  de  Med., 
•  Ian.  21,  •<)(»). 

Quinine  usually  proves  very  poteni  in 
preventing  or  at  least  mitigating  malarial 

disease,  even  in  very  unhealthy  locali- 
ties. Three  to  4'/,  grains  a  day  can  he 
employed    for   months   with  impunity. 

4 


The  daily  dose  should  not  exceed  9  grains 
nor  be  less  than  2  grains.  Hydrochloride 
preferable  to  the  sulphate  and  is  better 
supported.  If  added  to  coffee,  that  pre- 
cipitates a  portion  of  the  quinine.  La- 
veran  (Med.  Record,  Oct.  2,  '97). 

Prophylactic  measures  adopted  in 
Central  Africa:  Certain  amount  of 
credit  given  to  the  exhibition  of  small 
daily  doses  of  quinine,  commenced  at  sea 
before  entering  the  country  and  con- 
tinued whenever  the  line  of  march  lay 
along  the  course  of  low-banked  rivers  or 
cut  across  marshes  or  alluvial  plains  at 
a  watershed-foot.  The  doses  about  4 
grains  per  diem,  and  were  never  pushed 
to  the  causation  of  symptoms.  In  Cen- 
tral Africa  it  was  found  after  experience 
that  the  best  clinical  results  were  ob- 
tained by  apportioning  to  each  indi- 
vidual such  an  amount  of  the  drug  as 
sufficed  to  produce  in  him  an  aural  dis- 
turbance indicative  of  the  commence- 
ment of  quininism.  S.  K.  Smith  (Lancet, 
Apr.  10,  '97). 

The  administration  of  even  small  doses 
of  quinine  over  a  certain  period  acts  in- 
juriously on  the  red  corpuscles,  but  clin- 
ical experience  shows  that  in  most  cases 
the  injurious  effect  of  quinine,  if  not  con- 
tinued over  too  long  a  time,  may  be  prac- 
tically ignored.  Most  people  can  take 
5  grains  of  quinine  daily  over  a  very  con- 
siderable period  without  any  appreciably 
injurious  effect.  For  persons  whose  stay 
in  malarial- stricken  districts  is  brief,  and 
where  the  malarial  parasite  is  virulent, 
this  dose  might  be  increased.  The 
prophylactic  dose  should  be  begun  two 
days  before  the  person  is  exposed  to  the 
action  of  malaria  and  to  be  continued  for 
ten  days  after  he  leaves  the  district. 
Solution  of  the  powder  preferred  to 
other  forms.  George  Thin  (Lancet,  Jan. 
25,  '98 ). 

Prophylaxis  against  tropical  malarial 
fever  in  our  camps  should  consist  of 
changing  the  clothes  before  retiring  at 
night,  avoidance  of  constipation,  and  a 
daily  ration  of  quinine,  to  which  whisky 
should  be  added  when  the  subject  has 
been  exposed  to  rain.  Sleeping  in  shacks 
or  in  tents  with  the  sides  open,  and  as 
far  as  possible  selecting  for  camps  high 
sites    exposed    to    wind    and  sunshine 

33 


514  MALARIAL  FEVERS.    PROPHYLAXIS.  MALE  FERX. 


should  be  encouraged.  Hammocks  should 
be  swung  at  least  three  feet  from  the 
ground;  in  more  permanent  locations 
beds  constructed  of  split  limbs  of  trees 
are  better  than  hammocks.  Mosquito- 
nettings  should  always  be  used;  and,  as 
the  mosquito  of  the  tropics  is  often 
smaller  than  his  fellow  of  the  Xorth,  a 
very  fine  mesh  is  indispensable.  To  these 
precautions  should  be  added  a  careful, 
systematic  medical  supervision  of  water- 
supplies,  kitchens,  and  diet;  a  daily  in- 
spection of  each  company  by  a  medical 
officer;  and,  finally,  rejection  at  recruit- 
ing-stations of  men  with  positive  his- 
tories of  malarial  infection,  and  the  in- 
validing home  of  all  patients  who  respond 
only  temporarily  to  treatment.  J.  E. 
Stubbert  (Med.  News,  July  30,  '98). 

Review  of  the  literature  of  the  last 
twelve  years,  including  the  observations 
of  explorers,  army-surgeons,  and  others: 

The  following  prophylactic  measures, 
carried  out  simultaneously,  are  necessary 
in  malarial  districts  to  insure  adequate 
protection:  — 

1.  To  avoid  contamination  through 
the  respired  air  and  inoculation  by  in- 
sects:— 

Unacclimatized  men,  white  or  black, 
should  not  be  employed  for  the  digging 
of  trenches,  the  erection  of  defenses,  or 
any  other  kind  of  work  involving  up- 
turning of  the  soil.  Xatives  should  alone 
be  utilized  for  this  work. 

High  ground  should  be  selected  for 
camp-sites,  windward,  if  possible,  of  any 
swamp,  pool,  stream,  etc.,  that  may  be 
in  the  neighborhood. 

The  men  should  sleep  as  high  above 
the  ground  as  possible  (not  less  than  two 
feet  and,  if  practicable,  from  twelve  to 
fifteen  feet)  and  be  provided  with  mos- 
quito-netting. 

While  crossing  malaria-laden  forests, 
glens,  lowlands,  swamps,  etc.,  the  men 
should  be  ordered  to  avoid  talking. 

2.  To  avoid  contamination  by  water:  — 
When  water  from  malarial  regions  i- 

alone  available  for  drinking-purposes,  it 
should  be  filtered,  or.  preferably,  steril- 
ized by  boiling. 

Bathing  should  not  be  permit  tod  when 
water  from  a  malarial  region  can  alone 
be  obtained,  but  washing  of  the  body 


with  such  water  is  permissible,  provided 
carbolic-acid  soap  be  employed. 

3.  To  prevent  the  development  of. ma- 
larial parasites  in  the  blood:  — 

Four  grains  of  hydrochlorate  of  qui- 
nine should  be  administered  morning  and 
evening  during  meals  as  prophylactic,  be- 
ginning two  days  before  the  malarious 
region  is  reached. 

4.  To  conserve  the  general  powers  of 
resistance  of  the  economy:  — 

Regular  and  frequent  periods  of  rest 
should  intersperse  long  marches.  Drench- 
ing and  wading  through  streams  should 
be  avoided  when  possible.  Varied  and 
adequate  food  should  be  furnished. 

The  head  should  be  so  protected  as  to 
secure  a  maximum  amount  of  coolness 
under  all  degrees  of  temperature,  a  head- 
gear such  as  the  solar  tepe  being  fur- 
nished for  this  purpose.  C.  E.  de  M. 
£ajous  (Monthly  Cyclo.  of  Pract.  Med., 
May,  '98). 

As  a  protection  against  mosquitoes  a 
piece  of  oak-punk  about  an  inch  square 
should  be  placed  at  bed-time  in  a  saucer 
on  a  metal  plate.  Upon  this  is  to  be  put 
a  large  pinch,  about  as  big  as  a  nut,  of 
powdered  pyrethrum,  and  when  the 
mosquitoes  get  troublesome  the  punk 
should  be  ignited.  The  smoke  produced 
by  the  burning  pyrethrum  M  ill  infallibly 
drive  away  the  mosquitoes  for  the  night. 
Editorial  (Gaz.  Hebdom.  de  Med.  et  de 
Chir.,  June  23,  '98). 

James  C.  Wilson, 
Thomas  G.  Ashtox, 

Philadelphia. 

MALE  FERN. — Male  fern  (aspidium, 
U.  S.  P.)  is  the  rhizome  of  Dryopteris 
filix  mas  and  of  Dryopteris  marginalis 
(nat.  order  Filices),  ferns  which  are 
found  in  almost  all  parts  of  the  globe, 
especially  so  the  former;  the  latter  is  in- 
digenous to  Xorth  America.  The  rhi- 
zome, which  deteriorates  on  keeping, 
has  a  sweetish-bitter,  astringent  taste, 
and  a  slight  odor.  It  contains  an  active 
principle,  filicic  acid:  a  fixed  oil.  a  vola- 
tile oil,  resin,  tannin,  etc.    The  ethereal 


MALE  FERX.  POISONING. 


515 


extract  deposits  a  yellowish-white,  granu-  | 
lar,  crystalline  substance  (filicie  acid),  | 
upon  which  the  medicinal  activity  de- 
pends.   The  oleoresin  is  a  thick,  dark- 
brown  fluid,  of  a  bitter  and  nauseous 
taste;  on  standing,  it  deposits  its  active  I 
constituent,   and   must,   therefore,  be 
thoroughly   mixed   before   being  dis- 
pensed. 

Preparations  and  Doses.  —  Aspidium 
(powdered  crude  drug),  1/2  to  1  1/2 
drachms. 

Oleoresina  aspidii,  1/2  to  1  drachm. 

Physiological  Action.  —  The  physio- 
logical effects  of  male  fern  are  usually  • 
attributed  to  an  amorphous  acid,  filicie  j 
acid;   but  the  oleoresin  is  thought  to 
contain  all  the  virtues  of  the  drug. 
Filicie  acid  first  causes  excitement  of  the 
nervous  system,  then  paralysis  Of  the  j 
latter,  of  the  muscular  system,  and  of  j 
the  heart  in  the  frog.    This  is  mainly  : 
due  to  its  depressing  effects  upon  the 
spinal  centres.    In  man  its  effects  are  , 
probably  similar,  judging  from  the  symp- 
toms, following  the  injection  of  an  over-  i 
dose,  mainly  marked  gastro-intestinal 
irritation,   weakness,  vertigo,  tremors, 
cramps,  amaurosis,  stupor,  and  coma. 
Male  fern  is  a  vermifuge,  i.e.,  it  expels 
the  tape-worm,  the   entozoon  against 
which  it  is  generally  employed. 

Poisoning  by  Male  Fern. — Toxic  doses  J 
of  the  ethereal  extract,  or  oleoresin,  cause 
irritation  of  the  gastro-intestinal  tract,  j 
vomiting,  purging,  and  great  pain  in  the 
abdomen.    If  absorbed,  it  acts  on  the  ! 
central  nervous  system  and  causes  cramps 
in  the  extremities,  giddiness,  amaurosis, 
paralysis,   collapse,   coma,   and   death,  j 
Albuminuria  and  glycosuria  are  occasion- 
ally produced  by  overdoses  of  male  fern. 
Poulssen,  Katamaya,  and  Okamoto  have 
found  that  castor-oil  and  other  fixed  oils 
increase  the  rapidity  of  absorption  of  the 
active  principle.  They  should  not.  there-  ' 


fore,  be  used  with,  or  after,  filix  mas. 
Six  drachms  have  proved  fatal  in  one 
adult,  12  drachms  in  another,  and  2 
drachms  in  a  child  5  1/2  years  old. 

Literature  of  '96-'97-'98. 

Study  of  the  influence  of  male  fern 
upon  the  blood,  and  tissues  of  rabbits. 
There  was  a  preliminary  examination  of 
each  animal  for  several  days,  in  order  to 
determine  the  normal  number  of  red  cells, 
the  proportion  of  haemoglobin,  and  the 
weight  of  the  body.  The  drug  was  ad- 
ministered through  a  sound  passed  into 
the  oesophagus.  As  soon  as  the  animal 
died  the  autopsy  was  performed,  and  frag- 
ments of  the  liver,  spleen,  bone-marrow, 
kidneys,  and  occasionally  of  the  heart 
and  central  nervous  system  were  hard- 
ened and  subsequently  sectioned.  Of  the 
eight  animals  experimented  on,  some 
were  poisoned  acutely  with  large  doses, 
and  others  gradually  with  frequent  small 
doses.  In  the  acute  cases  the  animals 
frequently  died,  and  examination  of  their 
bodies  failed  to  reveal  any  change  that 
accounted  for  death.  In  the  more  chronic 
cases,  considerable  change  in  the  consti- 
tution of  the  blood  was  not  infrequently 
observed.  This  usually  consisted  in  a 
diminution  in  the  number  of  red  cells 
and  in  the  proportion  of  haemoglobin, 
although  the  animals  had  lost  a  consider- 
able portion  of  liquid,  and  consequently 
the  blood  was  thickened.  Morphological 
changes  were  not  present.  The  glandular 
organs,  the  lungs,  the  heart,  and  the  nerv- 
ous system  were  apparently  normal.  The 
liver,  the  spleen,  the  bone-marrow,  and 
occasionally  the  kidneys  often  contained 
a  considerable  excess  of  iron-pigment. 
The  author  is  convinced  that  the  liver  is 
the  organ  in  which  the  red  cells  are  de- 
stroyed, and  that  the  pigment  deposited 
in  it  is  subsequently  conveyed  by  the  cir- 
culation to  the  other  organs.  In  his  own 
observations,  t lie  granules  of  hemosiderin 
appeared  in  the  liver  invariably  one  or 
two  days  earlier  than  in  the  spleen.  The 
accumulation  of  the  pigment  in  the  liver 
does  not  appear  to  indicate  that  the  liver- 
cells  are  incapable  of  getting  rid  of  it, 
particularly  on  account  of  its  extensive 
metastasis.    Icterus  did  not  occur  in  any 


516  MALE  FERN. 

case,  and  there  was  no  reason  to  believe 
that,  aside  from  the  increased  activity  of 
the  liver-cells  caused  by  their  participa- 
tion in  the  destruction  of  the  erythro- 
cytes, there  was  any  injurious  influence 
exerted  upon  the  organ.  Georgiewsky 
(Phila.  Med.  Jour.,  iii,  p.  83,  '98). 

Treatment  of  Poisoning  by  Male  Fern. 
— The  poison  should  be  removed  by 
evacuants,  avoiding  the  use  of  castor  or 
other  oils.  Stimulants  by  mouth  and  by 
hypodermic  injection  are  useful  to  com- 
bat depression  and  collapse. 

Therapeutics.  —  Tape-worm.  —  Male 
fern  is  used  almost  exclusively  as  a 
remedy  against  tape-worn.  It  is  seldom 
or  never  given  in  the  crude  form,  or 
powder,  but  in  the  form  of  the  oleoresin, 
or  ethereal  extract  (non-official).  The 
oleoresin,  being  nauseous  in  taste,  is 
given  best  in  capsules;  it  can  be  given 
in  milk  or  gum-water,  but  is  not  as 
readily  retained.  A  milk  diet  having 
been  adhered  to  for  a  day  or  two,  a 
purgative  is  given,  followed  by  the  oleo- 
resin of  male  fern,  and  that  in  turn  is 
followed  by  another  purgative.  The 
•oleoresin  given  in  divided  doses,  an  hour 
apart,  acts  better  in  some  cases. 

Eczema. — Lanara  has  used  male  fern 
as  an  application  in  eczema: — 

I£  Extract  of  male  fern,  alcoholic, 

7  1/2  drachms. 
Alcohol,  1/2  ounce. 
Extract  of  myrrh, 
Extract    of   opium,    of    each,  1 

drachm. — M. 

Cysticercus. —  Feletti  has  observed 
improvement  in  several  cases  of  cysti- 
cercus disease  following  the  use  of  the 
ethereal  extract  of  male  fern,  more  espe- 
cially when  the  lesions  were  in  the  sub- 
cutaneous or  muscular  tissues. 

MALIGNANT  PUSTULE.  See  An- 
thrax. 


MALT. 

MALT.— Malt  is  prepared  from  the 
seed  of  barley  (Hordeum  distichum,  order 
Graminaciat)  by  the  process  of  artificial 
germination  and  subsequent  desiccation. 
The  barley-grains  are  soaked  in  water 
until  soft.  The  water  is  then  drained 
off  and  the  grain  is  placed  in  suitable 
receptacles  and  subjected  to  an  elevated 
temperature  for  several  days.  It  is  then 
placed  in  heaps,  in  a  darkened  room, 
where  it  is  allowed  to  germinate  until 
the  plumule  has  grown  to  be  half  as  long 
as  the  seed.  The  germination  is  then 
checked  by  the  application  of  heat,  which 
is  maintained  until  it  is  perfectly  dry, 
when  it  has  become  what  is  known  as 
malt.  If  the  last  heat  be  a  low  one  pale 
or  amber  malt  results;  if  dark  malt  is 
desired  the  heat  applied  is  higher  and 
the  malt  may  be  almost  roasted.  The 

I  former  varieties  are  used  in  medicine,  the 
latter  for  making  porter  and  dark  beers. 
Malt  has  a  sweet  taste  and  an  agreeable 
odor.  In  the  process  of  malting  the 
albumins  are  softened  and  made  more 
spongy,  the  starch  is  changed  by  the  ac- 

I  tion  of  the  vegetable  diastase,  resident  in 
the  grain,  with  dextrin  and  maltose 
(malt-sugar). 

Diastase,  or  maltine,  is  closely  allied 
to  ptyalin  and  to  pancreatin.  Their  ac- 
tion upon  starch  is  similar,  if  not  iden- 
tical. Eaw  starch  is  very  slowly  acted 
upon.  On  cooked  starch  it  first  pro- 
duces a  liquefying  action,  afterward  eon- 
verting  it  into  dextrin  and  later  into 
maltose.  These  ferments  act  best  in  a 
neutral  medium.  Its  action  is  slow  in 
an  alkaline  medium  and  is  Inhibited  or 
even  destroyed  by  the  presence  of  an 
acid. 

Malt  is  used  by  brewers  to  make  beer, 
ale,  and  porter,  and  by  distillers  to  make 
spirits.  Malt  enters  into  the  combina- 
tion of  many  foods  designed  for  infants 
and  invalids,  of  which  Liebiafs  is  the 


MAMMARY  GLAND. 


GALACTORRHEA. 


517 


type,  either  with  or  without  the  addi- 
tion of  milk. 

Malt  is  usually  employed  in  the  form 
of  the  extract,  which  is  made  by  mixing 
the  malt  with  water  at  a  moderate  heat 
(under  160°  F.).  The  mixture  is  left 
until  all  the  starchy  matter  has  been 
changed  into  dextrin  and  maltose,  when 
it  is  evaporated  in  vacuum-pans  to  the 
consistency  of  thick  honey.  If  the  water 
is  entirely  extracted  in  the  vacuum-ap- 
paratus, dry  extract  of  malt  is  obtained, 
which  is  the  form  used  in  the  prepara- 
tion of  foods  for  invalids  and  children. 
Another  form  of  liquid  malt  (so-called 
diastasic  extract  of  malt)  is  prepared  by 
macerating  well-malted  barley  in  warm 
water  for  several  hours;  the  infusion  is 
then  simmered  with  fresh  hops  at  a  tem- 
perature under  160°  F.,  to  retain  the 
diastase  and  other  albuminoids  unim- 
paired, and  then  subjected  to  fermenta- 
tion. The  resultant  liquid  contains  alco- 
hol from  a  trace  up  to  10  per  cent.  It 
resembles  porter  or  brown-stout  in  taste 
and  appearance. 

The  ordinary  extract  of  malt,  resem- 
bling honey,  is  a  good  vehicle  for  cod- 
liver-oil,  forming  with  it  an  excellent 
emulsion.  It  also  serves  as  a  vehicle  for 
iron,  quinine,  the  hypophosphites,  pep- 
sin, cascara,  peptones,  etc. 

Physiological  Action.  —  The  claims 
that  malt  is  a  valuable  reconstructive 
and  digestant,  though  to  a  degree  sus- 
tained by  clinical  observation,  are  not 
accounted  for  by  what  is  thought  to  be 
ils  behavior  in  the  stomach.  The  ob- 
servations of  Chittenden  and  Cummins 
would  lend  to  demonstrate  that  the  dias- 
tase—  a  ferment,  formed  during  the 
germination  of  malt  acid,  is  capable  of 
converting  nearly  two  thousand  parts  of 
starch  into  dextrin  and  glucose — is  de- 
stroyed by  the  gastric  juice.  It  must, 
therefore,  be  inert  when  the  duodenum 


is  reached.  Again,  the  secretions  being 
alkaline,  any  diastase  not  affected  by  the 
gastric  juice  would  be  hampered  here, 
since  it  is  known  to  act  imperfectly  in 
an  alkaline  medium.  A  neutral  solution 
is  required  to  obtain  its  best  effects. 
That  its  physiological  effects  are  still 
practically  unknown  is  apparent. 

Therapeutics. — Malt  is  a  food-element, 
since  it  contains  all  the  nutritive  sub- 
stances of  malted  barley  and  the  ferment 
diastase  which  aids  in  the  digestion  of 
starchy  foods.  It  is  of  pleasant  taste  and 
can  be  taken  alone,  on  bread,  or  in  milk. 
It  may  also  be  taken  as  a  food  in  the 
form  of  an  emulsion  wTith  an  equal  quan- 
tity of  codliver-oil.  It  is  useful  in  the 
wasting  diseases,  especially  in  marasmus 
and  tuberculosis.  Extract  of  malt  is 
often  retained  when  codliver-oil  is  not 
tolerated. 

MALTA  FEVER.  See  Malarial 
Fevers. 

MAMMARY  GLAND,  DISEASES  OF. 

— Under  this  heading  will  be  considered 
the  following  subjects:  Excessive  secre- 
tion of  milk,  inflammatory  disorders  of 
the  nipples,  mastitis,  and  galactocele. 
Tumors  of  the  breast  will  be  reviewed 
under  Tumors. 

Agalactia,  or  insufficiency  of  milk- 
secretion,  has  been  treated  under  that 
head  in  the  first  volume. 

Galactorrhea. — Galactorrhoea,  or  ex- 
cessive secretion  of  milk,  cannot  be  con- 
sidered as  a  pathological  condition,  ex- 
cept when  it  is  exhausting  the  strength 
of  the  patient,  or  when  the  profuse  pro- 
duction of  milk  continues  long  after 
lactation  has  been  suspended.  The  nor- 
mal production  in  health  approximates 
three  pints  in  the  twenty-four  hours. 
Instances  have  been  reported  in  which 
as  much  as  seven  quarts  were  secreted 


518 


MAMMARY  GLAND.    DISORDERS  OF  THE  NIPPLES. 


daily  (de  Mussy).  It  is  evident  that  such 
a  degree  of  hypersecretion  need  not  be  ; 
reached  before  marked  emaciation,  anse-  i 
mia,  and  even  hectic  symptoms  appear.  ! 
This  is  especially  apt  to  be  the  case  when  ! 
loss  of  appetite  attends  the  case — not  an  \ 
unusual  feature. 

Treatment. — The  active  production  of  ; 
milk  should  be  as  much  as  possible  ar- 
rested, but  not  too  suddenly.  In  mild 
cases  suckling  should  be  gradually  aban- 
doned, the  infant  being  increasingly 
nourished  with  artificial  foods,  and  tonics 
be  administered  to  the  patient.  In  the 
meantime  the  breasts  should  be  sup- 
ported by  means  of  bandages. 

Overfilling  of  the  glands  is  treated  by 
restricted  liquid  diet,  gentle  saline  laxa- 
tives, and  firm  compression  by  bandages  - 
over  lower  third  of  breasts.  In  caring 
for  the  breasts,  patient's  bowels  should 
be  kept  open  from  the  second  day  by 
small,  repeated  doses  of  compound  lico- 
rice-powder, or  pil.  rhei  comp.  The  nipple 
is  washed  in  warm  water  before  and  after 
nursing  and  smeared  with  castor-oil.  If 
the  nipple  becomes  chapped  or  excoriated, 
the  cracks  are  touched  with  10-per-cent. 
nitrate-of-silver  solution  once  a  day. 
C.  M.  Wilson  (Times  and  Register,  Dec. 
20,  '91). 

As  soon  as  the  child  can  be  weaned, 
iodide  of  potassium  can  be  employed  in 
increasing  doses,  beginning  with  5  grains 
three  times  a  day. 

Literature  of  'QG-'dl-'dS. 

Effect  of  iodide  of  potassium  tested  on 
nursing  women.  From  six  observations 
it  was  found  that  the  coming  of  the  milk 
after  labor  is  not  delayed,  that  the  course 
of  the  lactation  is  not  interfered  with, 
and  that  the  infant  does  not  suffer.  G. 
Fieux  (Rev.  Obstet.  Internat.,  May  1, 
'97). 

Belladonna  plasters  so  cut  as  to  form 
shallow  cones  leaving  an  opening  for  the 
nipple  are  then  applied  over  each  breast, 
the  latter  being  still  supported  with  ■ 


bandages.  Belladonna  ointment  can  be 
used  instead  if  the  glands  are  sensitive. 
As  a  tonic  Mariani's  coca-wine  can  ad- 
vantageously be  employed,  a  wineglass- 
ful  being  given  between  meals.  Cocaine 
and  mint  have  also  been  recommended, 
but  the  danger  of  cocaine  habit  should 
always  be  borne  in  mind. 

Antipyrine  renders  marked  service  in 
arresting  the  secretion  of  milk  in  newly- 
delivered  women,  provided  the  kidneys 
are  normal.  The  drug  is  administered 
in  4-grain  capsules;  every  two  hours,  for 
two  days,  or  until  GO  grains  have  been 
taken, — a  quantity  sufficient  usually  to 
produce  the  desired  effect.  Guibert 
(Lyon  Med.,  Aug.  9,  '91). 

Literature  of  '96-'97-'98. 

Conclusions  in  regard  to  antipyrine  in 
puerperal  women  are  as  follow:  — 

1.  Antipyrine  can  be  readily  discovered 
in  the  milk. 

2.  Given  in  two  doses  of  15  grains  each, 
at  two-hour  intervals,  it  was  discovered 
in  the  milk  five,  six,  and  eight  hours 
after  ingestion,  and  in  some  cases  as  long 
as  eighteen  hours. 

3.  The  drug  was  found  to  be  excreted 
very  slowly,  and  was  always  in  very 
small  amount  in  the  milk. 

4.  It  had  no  influence  on  the  quality  of 
milk. 

5.  It  had  no  effect  on  the  secretion  of 
milk. 

(i.  The  infants  showed  no  symptoms 
while  the  mothers  were  taking  anti- 
pyrine, and  they  also  rapidly  gained 
weight. 

It  is  certainly  justifiable  to  use  anti- 
pyrine in  nursing  women,  more  especially 
since  it  is  of  undoubted  value  in  check- 
ing after-pains.  Fieux  (Archiv.  Clin,  de 
Bordeaux,  Oct.,  '97). 

"When  the  accumulation  of  milk  can- 
not be  rapidly  curtailed  it  should  be 
drawn  by  means  of  a  breast-reliever. 

Disorders  of  the  Nipples. — Although 
apparently  trivial,  these  disorders  are 
often  the  cause  of  great  suffering  to 


MAMMARY  GLAND.    DISORDERS  OF  THE  XIPPLES. 


519 


nursing  women,  and  therefore  merit  at-  I 
tention. 

Defects  of  Development.  —  Short,  [ 
depressed,  and  otherwise  imperfectly-de- 
veloped nipples  —  generally  the  result 
of  corset-pressure — are  frequently  the 
seat  of  inflammatory  disorders  during  a 
period  of  lactation  and  should  be  care- 
fully watched. 

Out  of  525  in  childbed  only  one-half 
could  suckle  thoroughly  in  the  first  two 
weeks.  The  development  of  the  nipple 
bore  a  direct  relation  to  the  value  of  the 
breast  as  a  secretory  organ.  Wiedow 
(Centralb.  f.  Gynak.,  No.  29,  '95). 

The  undue  suction  to  which  they  are 
necessarily  submitted,  the  delicacy  of  the 
tissues,  any  abnormal  condition  of  the 
milk,  the  augmented  flow  of  saliva  which 
the  increased  efforts  of  the  infants  in- 
duce, all  tend  to  start  a  folliculitis.  This 
soon  develops  into  ulcerative  fissures  that 
become  excruciatingly  painful.  They 
bleed  easily  and  may  cause,  through  the 
suffering  induced,  general  and  even  men- 
tal disorders  quite  out  of  proportion  to 
their  cause.  Small  abscesses  may  follow 
and  greatly  compromise  the  value  of  the 
nipple:  an  efficient  portion  of  the  appa- 
ratus of  lactation. 

Treatment.  —  These  complications 
should  be  anticipated.  Some  time  before 
parturition  the  nipple  should  be  manip- 
ulated daily,  the  aim  being  to  bring 
blood  to  them  and  to  increase  their 
nutrition  by  gentle  efforts  to  encourage 
their  protrusion.  Buccal  or  instrumental 
suction  is  recommended  by  many  ac- 
coucheurs. They  should  be  washed 
daily  with  a  weak  boric-acid  solution 
and  carefully  dried.  The  manipulation 
gradually  accustoms  the  nipple  to  me- 
chanical irritation  and  by  the  time  the 
infant  is  born  they  are  better  able  to 
stand  that  involved  in  the  suckling  proc- 
ess. 


Free  use  of  alcohol  as  a  wash  for  the 
nipples  during  the  last  month  of  preg- 
nancy recommended.  In  case  a  fissure 
should  develop  a  nipple-shield  should  be 
used,  and  if  it  persist  the  fissure  should 
be  thoroughly  cauterized.  Auvard 
(LTJnion  Med.,  July  19,  '88). 

Depressed  and  useless  nipples  have 
been  operated  upon  as  follows:  — 

An  assistant,  with  a  pair  of  vulsella 
forceps,  seizes  the  nipple  and  drags  it  out 
to  a  length  somewhat  greater  than  natu- 
ral; the  operator,  with  a  pair  of  curved 
scissors,  beginning,  at  a  point  about  V3 
inch  from  the  apex,  excises  a  diamond- 
shaped  piece  of  skin,  extending  out  on 
the  breast  about  2  1/2  inches  and  about 
V2  to  ZU  inch  broad  at  its  centre.  The 
fat  is  cleaned  away  down  to  the  fascia, 
which  protects  the  ducts  from  injury. 
Three  such  areas  of  denudation  are  made. 
Beginning  in  the  denuded  area,  a  catgut 
suture  is  passed  in  and  out  through  the 
fascia,  purse-string  fashion,  emerging  at 
the  point  of  entrance  and  encircling  the 
base  of  the  newly-designed  nipple.  This 
is  now  tied  snugly,  and,  if  properly 
passed,  will  hold  the  nipple  out  well  after 
the  vulsella  has  been  removed.  The  de- 
nuded areas  are  now  covered  (as  is  the 
catgut  suture  and  its  knot)  by  drawing 
the  skin  of  the  diamond-shaped  incision 
together  with  silk.  A  dressing  is  then 
applied  so  as  to  keep  the  breasts  as  much 
at  rest  as  possible,  when  union  by  first 
intention  is  usually  found  to  have  oc- 
curred. Treatment  must  not  cease  with 
the  withdrawal  of  the  sutures,  but  the 
nipples  must  be  protected  by  a  suitable 
shield.  Axford  (Annals  of  Surg.,  Apr., 
'89). 

Literature  of  '96-'97-'98. 

Following  method  has  proved  success- 
ful in  prevention  of  sore  nipples:  — 
Lanolin  (Liebriech),  1  ounce. 

Dispense  in  glass  or  porcelain  screw-cap 
jar. 

Sig. :  For  external  use  every  night. 

Patient  begins  its  use  from  four  to 
six  weeks  before  the  expected  date  of 
confinement  and  continues  until  delivery. 
Every  night  at  bed-time  a  small  portion 
of  lanolin  is  thoroughly  worked  into  each 
nipple  with  the  thumb  and  fingers.  In 
the  morning  it  is  removed  by  a  soft  nail- 


520 


MAMMARY  GLAND.    ULCERATION  OF  THE  NIPPLE. 


brush  which  is  well-soaked.  The  nipple 
should  be  brushed  with  lukewarm  water 
and  any  mild,  pure  soap  (preferably 
a  white  soap),  giving  it  a  thorough  lath- 
ering for  three  or  four  minutes.  It 
should  afterward  be  rinsed  with  fresh 
water  and  dried  as  after  ordinary  bath- 
ing. J.  Milton  Mabbott  (N.  Y.  Med. 
Jour.,  Sept.  10,  '98). 

Instrument  for  stimulating  and  irri- 
tating the  mammse  employed  with  bene- 
fit. It  consists  of  a  large  hollow  hemi- 
sphere inclosing  the  entire  breast,  with  an 
aspirating  bulb.  Every  morning  the  in- 
strument is  applied  and  the  breast  as- 
pirated. As  soon  as  pain  is  felt  the  aspi- 
ration is  stopped  and  the  apparatus  is 
left  in  place  for  twenty  or  thirty  minutes. 

This  treatment  is  used  in  the  following 
four  classes  of  cases:  (1)  undeveloped 
breasts;  (2)  obstinate  vomiting  of  preg- 
nancy; (3)  debility  in  young  girls  at  the 
period  of  puberty;  and  (4)  chlorosis. 
Dumas  (Jour,  de  Med.  de  Paris,  19,  vi, 
'98). 

Ulceration  of  the  Nipple. — Ery- 
thema frequently  occurs  as  a  complica- 
tion of  lactation  particularly  in  primip- 
arse.  Far  more  distressing,  however,  is 
a  condition  due  to  the  fact  that  the  co- 
lostrum causes  maceration  of  the  epithe- 
lium of  the  nipple;  small  vesicles  appear 
which,  if  not  arrested  by  timely  treat- 
ment, generally  rupture.  The  erosions 
thus  formed  become  covered  with  scabs, 
under  which  healing  would  normally 
occur;  but,  sucking  being  continued,  the 
erosions  are  transformed  into  ulcerating 
fissures,  which  sometimes  involve  quite 
deep  destruction  of  tissue.  Occasionally 
the  small  vesicles,  instead  of  being  sep- 
arated, become  confluent,  and,  the  entire 
epithelial  covering  of  the  nipple  being- 
compromised,  a  raspberry-like  nipple  re- 
sults. These  conditions  are  sometimes 
greatly  aggravated  by  an  unhealthy  con- 
dition of  the  infant's  mouth — which 
should  always  receive  considerable  at- 
tention when  mammary  disorders  are 
present. 


Fissures  of  the  nipple  are  exceedingly 
painful,  as  already  stated.  They  are 
most  frequently  met  with  at  the  apex 
and  the  base  of  nipple,  where  it  meets 
the  areola.  In  the  latter  case  the  suction 
of  the  child  tends  to  tear  them  open,  as 
it  wears;  hence  the  excruciating  suffer- 
ing induced.  They  usually  appear  the 
fourth  day,  but  sometimes  earlier,  and 
quite  marked  febrile  symptoms  may  be 
induced. 

Treatment. — It  is  evident  that  the  pre- 
vention here,  first,  of  the  primary  irrita- 
tion, and,  if  this  is  present,  of  the  sec- 
ondary manifestations,  are  indicated. 
Scrupulous  cleanliness  of  the  nipple  will 
prevent  accumulation  of  colostrum  and 
the  primary  erosions;  hence  this  should 
be  insisted  upon.  Both  nipples  should 
be  carefully  washed  with  a  weak  boric- 
acid  solution,  not  only  after  nursing,  but 
immediately  before,  and  they  should  be 
carefully  dried. 

[Great  care  must  be  taken  during  lac- 
tation to  keep  the  child's  mouth  clean 
and  the  nipple  carefully  washed  with 
some  antiseptic.  Should  there  be  any 
evidence  of  a  threatening  mastitis  nurs- 
ing should  cease  at  once.  W.  L.  Rich- 
ardson, Assoc.  Ed.,  Annual,  '89.] 

When  local  lesions  exist,  suspension 
of  lactation  on  the  affected  side  causes 
them  to  disappear  in  a  few  days,  pro- 
vided adequate  cleanliness  is  insured. 
When  but  one  nipple  is  involved,  there- 
fore, it  can  be  allowed  to  rest,  the  other 
being  used  for  suckling.  A  breast-pump 
may  be  used  to  draw  the  milk  from  the 
disordered  breast  to  avoid  undue  ac- 
cumulation of  milk.  Buccal  suction,  by 
the  nurse  or  the  husband,  was  formerly 
recommended:  but.  the  condition  of  the 
mouth  being  unknown,  the  breast-pump 
is  to  be  preferred — if  kept  very  clean. 

Simple  erosions  usually  yield  promptly 
to  hot  water  and  laudanum,  or  Goulard's 
:  extract,  the  nipple  being  kept  covered 


MAMMARY  GLAND. 


ULCERATION  OF  THE  NIPPLE. 


521 


with,  a  light  compress  soaked  in  either 
of  these  solutions.  At  night  carbolized 
ointment  is  preferable,  to  avoid  adhesion 
of  compress  to  the  hard  surfaces  when 
the  liquid  has  evaporated. 

Excoriations  of  the  nipple  occasioned 
by  nursing  should  be  painted  over  by  a 
solution  of  gutta-percha  in  chloroform. 
This  application  covers  the  excoriations 
with  a  film,  which  is  not  removed  by  the 
application  of  the  child  to  the  breast. 
Monti  (Lea  Nouv.  Rem.,  No.  4,  '88). 

Dermatol  mixed  with  an  equal  quan- 
tity of  castor-oil  used  in  treatment  of  sore 
nipples.  It  is  not  necessary  that  the 
breast  be  thoroughly  cleansed  before  the 
child  receives  its  nourishment.  P.  Gross- 
man (Omaha  Clinic,  Oct.,  '91). 

Literature  of  '96-'97-'98. 

In  erosions  of  the  nipple  the  nipple 
should  be  washed  with  4-per-cent.  solu- 
tion, after  each  nursing,  then  a  layer  of 
cotton  dipped  in  the  same  solution  is  ap- 
plied over  it  and  the  entire  breast,  and 
this  is,  in  turn,  covered  with  gutta-percha 
cloth.  Dressing  should  be  renewed  fre- 
quently. If  this  fails,  steresol  should  be 
applied  to  the  affected  part  after  drawing 
the  lips  of  the  fissure  together;  ten 
minutes  later  another  coat  of  steresol  to 
be  applied.  In  fifteen  minutes  the  child 
can  take  the  breast,  as  the  steresol  forms 
an  impermeable  varnish.  No  dressing  is 
necessary.  Audebert  (Arch,  de  Gyn.  et 
de  Tocol.,  May,  '96). 

Eczema  of  the  nipples  is  sometimes 
taken  for  simple  erosions/  but  it  yields 
to  the  same  measures.  The  salicylic- 
acid  ointment  is  also  of  value. 

When  fissures  are  present,  the  same 
measures  are  indicated,  but  in  addition 
stimulation  by  means  of  nitrate  of  silver 
is  required.  The  nipple  being  washed 
and  carefully  dried,  the  mitigated  stick, 
finely  pointed,  is  gently  applied  to  each 
fissile;  {lie  moisture  within  the  latter 
affords  precisely  that  needed  to  obtain 
the  best  effects  from  the  remedy.  Care 
should  be  taken  not  to  touch  the  surface 
of  the  nipple. 


In  the  treatment  of  fissured  nipple, 
when  the  cracks  are  at  all  extensive,  ex- 
cellent results  can  be  secured  by  the  ap- 
plication of  an  ointment  made  up  of  equal 
parts  of  castor-oil  and  subnitrate  of  bis- 
muth. Before  application,  the  nipple 
and  surrounding  skin  should  be  carefully 
cleansed  and  disinfected,  and  then  the 
ointment  should  be  smeared  on  plenti- 
fully. If  it  is  necessary  for  the  child  to 
nurse  from  the  affected  nipple,  it  can  be 
allowed  to  do  so  without  the  necessity  of 
removing  the  ointment  from  the  nipple. 

For  engorgement  and  pain  in  the  mam- 
mary gland  itself,  which  often  accom- 
panies fissured  nipple,  excellent  results 
obtained  from  the  use  of  an  application 
of  lead-water  and  laudanum,  which  is 
applied  by  means  of  a  cloth  covering  the 
whole  breast,  renewed  at  frequent  inter- 
vals and  kept  in  place  by  a  suitable  mam- 
mary binder.  If  the  child  can  be  nursed 
from  the  other  breast  alone  it  is  safer 
to  draw  the  milk  from  the  affected  gland 
by  means  of  a  breast-pump  until  the  cure 
is  almost  complete.  If  it  is  necessary 
that  the  child  should  nurse  from  the 
cracked  nipple,  a  glass  nipple-shield  with 
a  rubber  tip  must  be  employed.  B.  C. 
Hirst  (Univ.  Med.  Mag.,  Mar.,  '91). 

Literature  of  '96-'97-'98. 

Orthoform  dressings  successfully  used 
in  fissured  breasts.  The  technique  of  the 
dressing  is  very  simple.  The  powdered 
orthoform  is  dusted  over  the  entire 
wound,  and  the  latter  is  covered  with  a 
compress  bearing  a  layer  of  the  remedy. 
Over  this  is  placed  a  layer  of  absorbent 
cotton,  and  finally  rubber  sheeting,  the 
whole  being  kept  in  place  by  a  bandage. 
In  a  few  minutes  the  patient  who  has 
up  to  then  felt  incessant  pains  at  the 
affected  part,  experiences  considerable 
relief.  Every  time  before  nursing  the 
child,  the  dressing  is  removed,  the  breast 
washed  with  warm  boric-acid  water, 
dried,  and  then  the  child  put  to  the 
breast.  At  the  first  sucking  some  pains 
are  felt,  but  these  rapidly  subside,  and 
after  the  nursing  is  over,  the  breast  is 
again  washed  with  boric-acid  water, 
dried,  and  the  same  orthoform  dressing 
applied.  The  analgesic  effect  of  the 
orthoform  being  very  durable,  it  suffices 


522  MAMMARY  GLAND.  MASTITIS. 


to  renew  the  dressing  at  first  twice  daily, 
then,  as  the  wound  begins  to  cicatrize 
and  the  pains  disappear,  once  only  per 
day. 

Besides  its  analgesic  effect,  orthoform 
exercises  in  the  wound  an  action  at  once 
siccative  and  antiseptic,  which  favors 
cicatrization.  In  29  cases  personally 
treated,  the  cure  was  brought  about  in 
from  four  to  five  days  on  the  average, 
the  patients  continuing  to  nurse  the  chil- 
dren. This  method  of  treatment  pos- 
sesses the  great  advantage  of  being  in- 
nocuous to  both  mother  and  child,  be- 
cause the  orthoform  is  entirely  free  from 
any  toxic  property.  Teisseire  (Sem. 
Med.,  xviii,  p.  ccxxvi). 

When  both  nipples  are  affected,  the 
infant  should  be  given  the  breast  as 
early  as  practicable,  i.e.,  as  long  as  the 
mother  can  stand  the  pressure  of  the 
secretion.  Prior  to  each  nursing  the 
nipple  should  be  carefully  washed  and  a 
nipple-shield  employed  to  protect  it. 
The  infant  sometimes  shows  evidence  of 
ill-humor  and  refuses  to  suck  through 
them;  but  a  little  patience  usually  con- 
trols the  situation.  A  glass  shield  with 
an  India-rubber  tip  is  to  be  preferred. 
It  should  be  kept  scrupulously  clean  and 
washed  immediately  before  and  after 
using.  If  the  infant  refuses  to  use  the 
tip,  wetting  the  latter  with  sweetened 
water  generally  acts  as  an  inducement. 
The  remedial  measures  already  indicated 
are  then  resorted  to. 

Mastitis. — Three  forms  of  inflamma- 
tion of  the  mammary  gland  are  recog- 
nized: the  subcutaneous,  the  submam- 
mary, and  the  parenchymatous. 

Subcutaneous  Inflammation. — This 
form  is  not  frequently  met  with,  and, 
though  it  may  present  itself  in  various 
parts  of  the  organ,  it  usually  confines 
itself  to  the  areola.  Its  development  is 
that  of  an  ordinary  boil;  the  spot  first 
becomes  red,  warm,  and  extremely  sen- 
sitive. When  located  in  the  areola,  sev- 
eral small  boil-like  projections  usually 


present  themselves,  which  seldom  do  not 
proceed  to  the  stage  of  suppuration. 
They  sometimes  assume  an  erysipelatous 
character. 

Submammary  Abscess.  —  The  space 
between  the  gland  proper  and  the  pec- 
toral muscle  over  which  it  lies  is  finished 
with  a  pad-like  layer  of  connective  tis- 
sue. Occasionally  this  becomes  the  seat 
of  an  abscess,  and,  when  the  suppuration 
is  extensive,  the  breast  is  raised  and  may 
be  moved  from  side  to  side.  The  local 
symptoms  differ  entirely  from  those  of 
the  former  condition.  There  is  but  little 
redness,  but  the  tissues  at  the  base  of 
the  organs  are  (edematous,  and  the 
neighboring  glands  are  generally  en- 
larged and  painful  to  the  touch.  There 
is  a  deep-seated,  dull  pain,  radiating  to 
the  arm  and  often  increased  by  the 
motions  of  the  latter.  There  is  marked 
fever,  especially  when  the  pus  has 
formed,  and  lasting  until  the  latter  is 
evacuated.  Pus  usually  points  not  far 
from  the  axilla,  and  when  the  abscess 
opens  of  its  own  accord  a  fistula  may 
ensue.  It  may  point  in  the  direction  of 
the  lacteal  ducts,  a  puriform  fluid  then 
being  secreted  with  the  milk. 

Parenchymatous  Abscess. — It  was 
formerly  believed  that  impediment  to 
the  escape  of  milk,  through  obstruction 
at  the  nipple,  by  stagnant  milk,  epi- 
thelium, etc.,  gave  rise  to  this  condition, 
but  modern  researches  have  shown  that 
all  forms  of  mammary  abscess  are  of 
microbic  origin.  Micro-organisms  origi- 
nating from  the  infant's  mouth  or  from 
hands  contaminated  with  lochial  dis- 
charge infect  the  nipple  and  readily 
reach  the  deeper  parts  directly  or 
through  the  lymphatics. 

Although  tubercle  in  the  human  sub- 
ject is  so  frequently  met  with  in  young 
married  women,  tubercular  mammitis  is 
extremely  rare.  S.  Woodhead  (Lancet, 
July  14.  '88). 


MAMMARY  GLAN 

Case  of  patient  of  slightly  tuberculous 
aspect  who,  on  absenting  herself  from  her 
infant  seven  and  a  half  hours,  found  that 
her  milk  was  horribly  foetid, — like  rotten  j 
eggs.    It  made  her  feel  ill,  and  her  rela-  j 
fives  could  not  stay  in  the  same  room  ; 
with  her.    Yet  the  infant  sucked  with  ! 
avidity;   it  was  violently  sick,  however. 
Next  day  the  milk  was  sweet,  and  the 
child  and  the  mother  were  quite  well. 
The  breasts  showed  no  sign  of  hardness, 
engorgement,    etc.     The    nipples  were 
healthy.    On  several  previous  occasions  j 
she  had  noticed  that  when  she  delayed 
giving  the  child  the  breast  at  the  usual  | 
times  the  milk  became  foetid.    Jorissenne  j 
(  Archives  de  Tocol.,  Feb.,  '91). 

Case  of  mammary  abscess  which  devel- 
oped from  infection  from  a  lochial  pad, 
which  the  patient  took  from  the  vulva 
and  applied  to  the  breast  as  a  protection 
from  cold.  Tarnier  (Jour,  des  Sages- 
femmes,  Oct.  1,  '91). 

Every  case  of  puerperal  mastitis  is  now  j 
known  to  be  due  to  infection.    The  bac- 
teria find  their  way  either  through  the 
milk-ducts  or  through  abrasions  or  fis-  j 
sures  of  the  nipple.    The  mastitis  which  | 
has  its  origin  through  the  milk-ducts  is 
of  a  parenchymatous   character,  while 
that  which  arises  from  fissures  or  abra- 
sions of  the  nipples  is  phlegmonous.  The 
retention  of  milk  within  the  breast  is  not, 
per  se,  a  cause  of  mammary  inflamma- 
tion, but  presence  of  bacteria  will  cause  \ 
a  decomposition  of  the  milk  thus  re- 
tained, and  then  give  rise  to  serious 
trouble.    Olshausen  (Deut.  med.  Woch., 
Apr.  5,  '88). 

In  most  carefully-kept  wards  there  are 
septic  germs  which  do  not  attain  suffi- 
cient virulence  to  occasion  serious  puer- 
peral accidents,  but  are  capable  of  caus- 
ing slight  temporary  febrile  disturbances. 
Remy  (Revue  Mod.  de  l'Est.,  Nov.  1,  '94). 

Verification  of  assertion  previously 
made  by  Genoud,  Etlinger,  and  others, 
that  in  the  majority  of  cases  the  milk 
of  perfectly-healthy  nurses  contained 
staphylococcus  albus,  which  explains  the 
ease  with  which  local  abscesses  may  be 
produced  by  pressure.  Charrin  (Revue 
des  Sci.  Mod.  en  France  et  ft  l'Etranger, 
Apr.  15,  '95). 


MASTITIS.  503 
Literature  of  '96-'97-'98. 

Six  cases  of  mastitis  in  one  ward  of  the 
Strasburg  Maternity,  all  occurring  within 
seventeen  days.  In  the  pus  from  the 
second  case  there  were  found  the  staphy- 
lococcus pyogenes  albus  and  the  micro- 
coccus tetragenus.  This  patient  infected 
the  third,  fifth,  and  sixth  cases,  and  as 
there  was  no  direct  contact,  the  infection 
must  have  been  carried  in  the  air.  These 
women  all  infected  their  infants  second- 
arily with  aphthous  stomatitis.  The  buc- 
cal secretion  showed,  along  with  lepto- 
thrix  and  streptococci,  the  staphylococcus 
pyogenes  albus.  A  mouse  inoculated 
therewith  died  in  two  days,  and  in  its 
organs  the  staphylococcus  was  found. 
In  the  fourth  case,  a  phthisical  primipara, 
the  mastitis  was  probably  tubercular  in 
nature,  although  no  tubercle  bacilli  were 
found  in  the  pus.  In  all  the  cases  an  ab- 
scess formed,  and  was  treated  surgically 
with  success.  H.  W.  Freund  (Centralb. 
f.  Gyniik.,  No.  41,  '96). 

Infective  germs  which  gain  access  to 
the  milk  do  so  simply  by  circulating 
through  the  glands  in  the  blood-stream. 
In  order  to  enter  the  milk  they  must 
pass  through  the  glandular  substance  of 
the  breast  through  some  injury  to  the 
gland-substance.  Bach  and  Weliminsky 
(Berliner  klin.  Woch.,  No.  45,  '97). 

Breasts  of  100  pregnant  women,  137 
puerperse,  and  60  children  carefully  ex- 
amined, with  the  following  results:  — 

In  the  majority  of  cases  the  secretions 
of  the  breast  in  pregnant  and  puerperal 
women  and  even  in  the  newborn  contain 
bacteria.  In  pregnant  women  this  was 
true  in  86  per  cent,  of  patients  examined, 
in  puerperal  women  in  91  per  cent.,  and 
in  newborn  infants  in  75  per  cent.  With 
very  few  exceptions  these  germs  were 
staphylococci,  and  especially  the  staphy- 
lococcus albus.  In  these  cases  no  point 
of  entry  of  these  germs  was  found  nor 
any  circumstances  explaining  their  pres- 
ence. They  must  have  entered  from 
without  through  the  nipples,  and  espe- 
cially from  the  areola  about  the  nipples. 
The  presence  of  these  germs  was  harmless 
to  mother  and  child.  The  infection  in 
mastitis  comes  from  without,  through  a 
lesion  in  the  skin  communicating  with 
the  lymph-channels,  and  spreads  itself  in 
\ 


524  MAMMARY  GLAND.  MASTITIS. 


different  ways  in  the  case  of  different 
germs.  The  ordinary  form  of  mastitis 
results  from  invasion  of  staphylococci, 
especially  the  staphylococcus  aureus. 
The  less  common  forms  of  mastitis,  such 
as  pseudo-erysipelas  and  retromammary 
abscess,  are  caused  by  streptococci.  jNIas- 
titis  caused  by  metastatic  infection 
through  the  blood-current  has  not  as  yet 
been  clearly  proved.  Kostlin  (Archiv  f. 
Gyn&k.,  13.  53,  H.  2,  '97). 

The  first  sign  is  the  presence  of  a  hard 
mass  in  the  tissues  of  the  organ.  At 
first  no  suffering  is  experienced,  but  pain 
is  finally  noticed  while  the  infant  is 
suckling.  The  presence  of  an  abscess 
now  becomes  manifest.  The  hard  mass 
previously  noticed  becomes  very  sensi- 
tive, the  overlying  skin  red,  resistant, 
hot,  and  oedematous,  and  the  organ,  as 
a  whole,  becomes  heavy.  The  skin  over 
the  abscess  finally  becomes  purplish  and 
less  tense,  and  fluctuation  is  soon  ob- 
tained. When  several  foci  of  inflamma- 
tion are  present,  they  may  suppurate 
successively,  and  the  series  of  abscesses 
thus  developed  may  destroy  the  entire 
gland,  and  the  sufferings  of  the  patient 
continue  months.  Septicaemia  and  gan- 
grene sometimes  complicate  such  cases. 
Even  in  the  comparatively  benign  cases 
generally  met  with  the  general  symp- 
toms are  sometimes  quite  marked. 

Pathology. — In  parenchymatous  in- 
flammation, according  to  Burnm,  who 
carefully  studied  the  question,  the  rapid 
proliferation  of  micro-organisms  in  the 
gland-structures  causes  fermentation  of 
the  milk,  and  transformation  of  its  sugar 
into  lactic  and  butyric  acids.  The  ca- 
sein becoming  coagulated,  the  glandular 
structures  become  engorged  with  the 
coagula,  and  inflammatory  changes  soon 
follow.  The  periglandular  tissues  be- 
come infiltrated  with  bacteria  and  leuco- 
cytes, while  the  epithelial  cells  lining 
the  glandular  structures  swell,  desqua- 
mate, and  disappear.     Purulent  miliary 


foci  soon  form  in  great  numbers,  and 
adjacent  foci  unite.  Irregular  cavities 
are  thus  formed  and  crossed  by  shreds 
of  partially-destroyed  tissues.  In  the 
walls  of  these  cavities  leucocytes  accu- 
mulate, which  stop  the  progress  of  the 
microbes,  preventing  farther  spreading 
of  the  disintegrating  process. 

Treatment. — The  treatment  of  sub- 
cutaneous inflammation  does  not  always 
vary  from  that  indicated  for  the  nipple. 
When,  notwithstanding  preventive  meas- 
ures, the  abscesses  are  formed,  the  pus 
must  be  evacuated.  An  important  point 
in  this  connection  is  that  any  incision 
I  made  should  invariably  radiate  from  the 
nipple, — i.e.,  cutting  away  from  the  lat- 
ter, toward  the  periphery  of  the  breast, 
as  the  spokes  of  a  wheel  radiate  from  the 
hub.  The  milk-ducts  are  thus  avoided, 
and  a  free  incision  can  be  made  without 
danger,  if  it  is  necessary. 

In  submammary  abscess  the  gland 
projects  outward  and  seems  to  rest  upon 
a  pillow  of  fluid.  The  quantity  of  pus 
is  sometimes  very  great, — over  a  pint. — 
the  connective  tissue  yielding  on  all  sides 
to  form  a  large  cavity  or  pocket.  When 
the  abscess  does  not  point  in  any  special 
direction,  the  presence  of  pus  may  be 
determined  by  means  of  an  aspirator- 
needle  inserted  at  the  base,  as  if  the 
organ  were  to  be  pierced.  An  incision 
can  then  be  made  near  the  lower  border 
of  the  gland — the  incision  likewise  radi- 
ating from  the  nipple.  The  pus  being 
fully  evacuated  with  antiseptic  precau- 
tions, the  abscess  should  be  washed  out 
with  a  3-per-cent.  solution  of  carbolic 
acid  and  drained  with  iodoform  gauze. 

Literature  of  '96-'97-'9S. 

Method  in  treatment  of  abscess  is  as 
follows:  As  soon  as  elastieity  and  deep 
fluctuation  are  evident.  &n  incision  is 
made  radiating  from  the  nipple  just  large 
enough  to  admit  the  index  linger  of  the 


MAMMARY  GLAND.  MASTITIS. 


525 


operator,  and  this  is  deepened  until  pus 
flows.  The  finger  is  now  passed  into  the 
cavity  and  it  will  be  brought  fairly  near 
the  surface  in  a  dependent  position,  and 
this  is  generally  at  the  thoracic  mam- 
mary junction.  Sometimes  the  finger 
passes  toward  the  axillary  margin,  and 
occasionally  the  cavity  is  so  large  that 
a  stout  bent  probe  must  be  used  to  indi- 
cate the  deepest  part  of  the  abscess.  In 
this  situation,  the  gland  being  well  raised 
by  an  assistant,  a  free  opening  is  to  be 
made,  large  enough  to  well  evacuate  the 
pus,  and,  the  finger  being  now  introduced 
through  this,  the  inferior  opening,  the 
operator  will  find  that  the  pus  has  bur- 
rowed about  and  is  contained  in  loculi 
bounded  by  fibrous  septa. 

The  cavity  is  well  flushed  out  with  an 
antiseptic  solution,  and  a  full-sized  tube 
is  introduced  from  below  (this  must  be 
confined  by  a  silk  thread).  The  opening 
made  near  the  nipple  is  closed  with  fine 
horsehair  and  painted  with  collodion. 

The  tube,  a  large  one,  can  be  left  in 
the  cavity  as  long  as  is  needful,  and  is 
slowly  shortened  and  withdrawn.  The 
wound  heals  with  a  larger  scar,  but  this 
is  completely  hidden  by  the  position  and 
volume  of  the  gland  above.  Shields 
(Lancet;  Boston  Med.  and  Surg.  Jour., 
June  11,  '90). 

In  parenchymatous  inflammation  the 
infant  must  be  weaned,  otherwise  the 
lesions  will  proceed  from  bad  to  worse. 
To  avoid  suffering  due  to  milk-produc- 
tion the  milk-pump  should  be  used.  In 
the  early  stage  the  abscesses  can  some- 
times be  stopped  by  the  application  of 
cold  compresses  constantly  renewed. 
The  old  treatment  is  now  discarded.  It 
is  important  to  support  and  immobilize 
the  breast  by  means  of  bandages  evenly 
applied. 

Inflammation  of  nipple  and  breast 
should  be  regarded  as  a  progressive  rather 
than  a  self-limited  disease,  arising  in 
tnosl  instances  from  septic  infection  of 
the  nipple.  Bandaging  advisable  after 
mastitis,  still-birth,  and  whenever  wean- 
ing is  necessary  on  account  of  mammary 
disorders.     Harris  (Annals  of  (!yn.  and 

Ped.,  Aug..  '05). 


Seventeen  cases  of  mastitis  treated  suc- 
cessfully by  evacuation  of  the  breast, 
partly  by  sucking  and  partly  by  a  sort 
of  massage  by  which  the  breast  is  com- 
pressed and  gently  rubbed  in  the  direc- 
tion of  the  nipple.  Kaarsberg  (Hosp.- 
tid.,  p.  573,  '95). 

Literature  of  '96-'97-'98. 

Abortive  treatment  of  threatened  ab- 
scess consists  in  placing  the  cathode  at 
some  distant  indifferent  point  and  apply- 
ing the  anode  as  directly  as  possible  to 
the  seat  of  trouble.  The  current  should 
be  from  5  to  10  milliamperes,  and  may 
be  continued  from  three  to  five  minutes. 
The  anode  should  be  large  enough  to 
almost  cover  the  affected  area.  Applica- 
tions may  be  made  daily.  Should,  how- 
ever, the  abscess  be  already  formed,  the 
cathode  is  applied  locally  for  its  electro- 
lytic effect,  and  the  current  must  be  a 
strong  one,  especially  in  old  abscesses 
with  a  well-defined  limiting  wall.  From 
100  to  200  milliamperes  are  required. 
The  cathode  may  usually  consist  of  a 
metal  stem  or  rod  lodged  within  the  ab- 
scess. A.  H.  P.  Leuf  (Med.  Council, 
Sept.,  '97), 

Expression  used  in  treatment  of  threat- 
ened abscess  of  the  breast.  Compression 
should  be  made  daily  from  the  circum- 
ference; in  a  few  days  the  induration 
will  subside.  In  no  case  has  the  method 
failed.  W.  B.  Warde  (Lancet,  Jan.  3, 
'98). 

Belladonna  ointment,  lead-water,  and 
laudanum  are  recommended  by  various 
clinicians.  Saline  cathartics  are  useful 
as  derivatives,  provided  the  patient  is  not 
too  weak. 

When  the  presence  of  pus  is  ascer- 
tained, it  should  be  evacuated  under 
strict  antiseptic  precautions,  an  incision 
one-half  inch  in  length,  radiating  from 
the  nipple,  being  made  in  the  most  de- 
pendent portion  of  the  organ.  The  cav- 
ity is  then  washed  out  with  an  antiseptic 
solution  and  drained. 

The  general  health  requires  consider- 
able attention,  the  strength  of  the  pa- 


526  MANGANESE.  POISONING. 


tient  bearing  considerably  upon  the  re- 
covery. Good  food,  tonics,  and  pure  air 
are  important  adjuvants. 

Galactocele. — This  condition  is  due  to 
the  distension  or  rupture  of  one  or  more 
lactiferous  tubes.  In  the  latter  case  the 
milk  flows  within  the  connective  tissue 
of  the  gland. 

Symptoms.  —  Two  varieties  of  the 
rather  rare  condition  are  met  with:  in 
the  one  the  accumulation  of  milk,  within 
the  duct  or  the  connective  tissue,  occurs 
near  the  nipple  and  superficially.  The 
appearance  is  typical,  more  or  less  large 
knob-like  projections  or  swelling  form- 
ing the  apex  of  the  gland.  It  usually 
appears  suddenly  while  suckling  the  in- 
fant, when  rupture  of  the  tube  occurs 
without  causing  much  local  distress.  In 
simple  dilatation  the  growth  is  gradual. 

The  second  variety  occurs  in  the  sub- 
stance of  the  organ,  forming  one  or  more 
irregular  lobular  projections,  that  are 
quite  firm  under  pressure,  especially  in 
cases  of  long  standing.  In  the  latter, 
when  due  to  rupture  of  the  ducts,  the 
accumulated  secretion  is  often  found 
hemmed  in  by  a  protective  cyst-wall. 
When  the  duct  is  simply  dilated,  the  wall 
is  formed  by  the  lactiferous  tube  itself. 
The  former  likewise  appears  more  or  less 
suddenly.  In  some  cases  the  gland  be- 
comes very  large,  and  as  much  as  five 
quarts  of  milk  have  been  withdrawn  by 
means  of  the  trocar. 

Treatment. — Aspiration  is  sometimes 
sufficient  to  cure  small  cysts:  but,  in 
the  majority  of  cases,  it  is  best  to  open 
the  distension  antiseptically  and  to  drain. 

MANDRAKE.    See  Podophyllum. 

MANGANESE.  —  Manganese  (manga- 
num)  is  a  very  hard  brittle  metal,  having 
a  metallic  lustre,  and  a  whitish-gray, 
metallic  fracture.  In  the  metallic  state 
it  is  not  used  in  medicine. 


Manganese  dioxide  (peroxide  or  bi- 
noxide),  or  black  oxide  of  manganese 
(mangani  dioxidum,  U.  S.  P.),  is  found 
native,  containing  at  least  66  per  cent, 
of  pure  dioxide.  It  occurs  as  a  heavy, 
black  powder,  and  is  soluble  in  hot  min- 
eral acids.   Dose,  2  to  15  grains. 

Manganese  sulphate  (mangani  sulphas, 
IT.  S.  P.)  occurs  in  transparent  pale-rose 
effervescent  prisms  having  a  bitterish, 
astringent  taste,  and  is  soluble  in  0.8 
parts  of  water.   Dose,  5  to  15  grains. 

Potassium  permanganate  (potassii  per- 
manganas,  U.  S.  P.)  occurs  in  dark-pur- 
ple, slender,  opaque  prisms,  having  a 
blue,  metallic  reflection,  and  a  sweet, 
with  astringent  after-  taste,  and  is  solu- 
ble in  16  parts  of  cold  water  and  3  parts 
of  boiling  water.  Permanganate  of  pot- 
ash, is  incompatible  with  all  oxidizable 
substances,  particularly  organic  ones. 
Dose,  V2  to  3  grains. 

The  liquor  ferri  mangani  peptonate 
(non-official)  is  very  generally  used. 
Dose,  1  to  4  drachms. 

Physiological  Action.  —  The  physio- 
logical action  of  manganese  is  not  estab- 
lished. Once  thought  to  be  a  chalybeate 
equal  to  iron,  it  failed  to  sustain  the 
reputation,  and  is  rarely  employed  by 
the  profession  in  the  treatment  of  anae- 
mia and  chlorosis.  Especially  has  it  been 
ostracized  since  Gahn  demonstrated  that 
there  was  considerable  doubt  as  to 
whether  it  entered  the  circulation  at  all, 
while  there  was  nothing  to  show  that  it 
was  taken  up  by  the  blood-corpuscles. 

Poisoning  by  Manganese.  —  A  c  r  t  e 
Poisoning. — In  toxic  doses  manganese 
causes  intense  gastro-enteric  inflamma- 
tion and  death  by  convulsion-^  Tn 
smaller  doses  it  lowers  the  action  of  the 
heart,  diminishes  the  pulse-rate,  and 
lessens  the  blood-pressure. 

Chronic  Poisoning.  —  Absorbed  in 
large  doses  and  for  a  considerable  period 


MANGANESE. 

it  acts  as  a  cumulative  poison,  induces 
acute  fatty  degeneration  of  the  liver,  a 
progressive  wasting  and  feebleness,  a 
staggering  gait;  and  paralysis  (paraple- 
gia). This  latter  variety  is  the  one  seen 
among  the  miners  of  the  metal. 

Therapeutics.  —  Menstrual  D  i  s  o  r  - 
ders. — Manganese  dioxide  has  been  used 
extensively  in  the  treatment  of  disorders 
of  the  uterine  functions,  especially  when 
due  to  a  functional  cause.  It  has  been 
used  in  membranous  dysmenorrhea  in 
doses  of  2  grains,  in  pill  or  capsule,  given 
four  or  five  times  daily.  In  amenorrhcea, 
of  acute  suppression  of  the  menses  from 
cold,  and  when  the  menstrual  discharge 
is  scanty  and  irregular,  manganese  is  of 
good  service. 

Some  200  cases  treated  with  perman- 
ganate of  potash.  It  was  found  of  service 
in  dysmenorrhcea  in  otherwise  healthy 
girls,  in  excessive  subinvolution  after 
childbirth,  in  atrophy  during  puerperal 
affections,  and  in  pelvic  peritonitis  after 
labor.  The  remedy  proved  of  little  avail 
in  affections  of  the  tubes  and  ovaries  in 
which  the  gonococcus  was  found,  and  in 
atrophic  conditions  of  the  uterus  from 
early  appearance  of  the  menopause.  Lvoff 
(Med.  News,  May  19,  '88). 

Literature  of  '96-'97-'98. 

Binoxide  of  manganese  used  for  many 
years  for  functional  derangements  of  the 
uterus  with  a  smaller  percentage  of  fail- 
ures than  from  any  other  drug. 

In  the  absence  of  organic  disease  it 
seems  to  have  the  power,  in  a  great  many 
cases,  of  bringing  the  menstrual  function 
back  to  the  normal  standard  in  whatever 
direction  1  lie  deviation  from  that  stand- 
ard may  have  been. 

In  painful  menstruation  beginning 
atymt  four  days  before  the  expected 
period,  and  continuing  until  the  flow  is 
fully  established,  it  will  generally  give  a 
measure  of  relief. 

The  headache  of  a  burning  character, 
and  limited  to  the  vertex,  which  so  fre- 
quently has  a  uterine  origin,  is  often 


THERAPEUTICS.  597 

promptly  relieved  by  two  or  three  doses 
of  the  drug,  administered  at  intervals  01 
two  or  three  hours. 

It  also  gives  decided  relief  to  the  hot 
flashes  attending  the  menopause,  if  the 
patient  takes  a  pill  of  2  grains  at  bed- 
time. 

The  dose  is  2  grains  three  times  a  day, 
but  as  it  is  absolutely  without  unpleasant 
effects,  it  may  be  given  in  much  larger 
quantity  and  at  much  shorter  intervals. 
For  its  effect  upon  the  periods  it  should 
be  given  for  three  or  four  days  before  the 
expected  time  and  continued  nearly  or 
quite  through  the  period,  this  being  re- 
peated for  several  consecutive  months. 
A.  II.  Smith  (Ga.  Jour,  of  Med.  and  Surg., 
Jan.,  '98). 

Anemia  and  Chlokosis. — In  anasmia 
and  chlorosis  manganese  is  beneficial, 
but  only  when  combined  with  iron. 
Gude's  liquor  mangani-ferri  peptonatus 
is  a  very  palatable  and  efficient  prepara- 
tion for  the  purpose.  It  has  an  agree- 
able, astringent,  but  non-metallic  taste, 
and  may  be  given  in  the  dose  of  a  des- 
sertspoonful to  a  tablespoonful  three  or 
four  times  daily,  alone  or  in  milk.  This 

I  preparation  increases  the  appetite,  does 

j  not  disorder  digestion,  and  can  be  taken 

j  steadily  for  a  long  period. 

Scrofula. — In  scrofula  and  debility 
due  to  prolonged  suppuration  the  non- 
official  syrup  of  the  iodide  of  iron  and 

!  manganese  is  a  remedy  of  great  value. 

Gastric  Disorders. — In  gastrodynia 
and  pyrosis,  the  dioxide,  in  doses  of  10 
to  15  grains,  is  recommended  by  Leared. 

Jaundice.  —  Malarial  jaundice  has 
been  relieved  by  the  sulphate  of  man- 
ganese in  doses  of  2  grains.  The  sul- 
phate, however,  has  an  irritating  effect 
on  the  bowel,  and  is  unsafe. 

Kheumatism.  —  The  internal  admin- 
istration of  potassium  permanganate  has 
been  advised  for  the  treatment  of  acute 
articular  rheumatism,   diphtheria,  and 


528  MANGANESE. 

diabetes.  Its  usefulness  in  the  diseases  is 
doubtful. 

Antidote  to  Morphine,  Phosphorus 
and  Snake-bite. — H.. William  Moor,  of 
New  York,  lias  shown  that  potash  per- 
manganate is  a  direct  chemical  antidote 
for  morphine,  but  is  without  effect  on 
atropine,  cocaine,  veratrine,  pilocarpine, 
aconitine,  and  strychnine.  An  equal 
quantity,  grain  for  grain,  of  perman- 
ganate is  antidotal  to  morphine.  In 
cases  of  poisoning  by  opium,  laudanum, 
or  the  uncombined  alkaloid,  he  advises 
acidulation  of  the  antidotal  solution  with 
dilute  sulphuric  acid,  or  white-wine 
vinegar,  in  order  that  the  insoluble  mor- 
phine may  be  converted  into  a  soluble 
salt.    (See  Opium.) 

Hagnos,  of  Budapest,  has  found  the 
permanganate  a  reliable  antidote  in 
phosphorus  poisoning.  After  washing 
out  the  stomach  he  introduces  a  pint  of 
a  yi0-per-cent.  solution  and  allows  it  to 
remain.  If  applied  immediately  after 
the  receipt  of  the  wound  it  is  efficacious 
in  snake-bite  poisoning. 

External  Uses. — Externally  the  per- 
manganate has  a  wide  field  of  usefulness. 
Applied  as  a  wash  or  on  compresses  of 
gauze  or  lint,  in  the  strength  of  2  to  10 
grains  to  the  ounce  of  water,  it  is  a  valu- 
able deodorizer  and  disinfectant  for 
sloughing  wounds,  cancerous  growths, 
ulcers,  gangrene,  and  caries.  Dilute 
solutions  have  a  stimulant  action  on  the 
tissues  and  favor  granulation  and  heal- 
ing. It  may  be  used  as  a  spray  in  ozsena 
or  as  a  mouth-wash  or  spray  in  diph- 
theria, scarlatina,  and  conditions  causing 
foul  breath. 

Upward  of  300  cases  of  toothache  from 
denial  caries  successfully  treated  by  ad- 
ministering V20  solution  of  permanganate 
of  potash  in  the  form  of  a  mouth-wash. 
One  tablespoonful  was  taken  into  the 
mouth  every  half-hour,  and  held  on  the 
affected  side  for  several  minutes.  The 


MEASLES. 

agonizing  pain  disappeared  in  a  few 
hours.  Popoff  (Russkaia  Med.,  No.  19, 
'87). 

Sponging  the  feet  with  permanganate 
solution  will  remove  the  odor  of  abnor- 
mal perspiration.  In  purulent  ophthal- 
mia permanganate  solutions  (1  to  2000 
or  1  to  5000)  have  been  found  useful. 
A  2-  to  5-per-cent.  solution  has  been  used 
with  benefit  in  leucorrhcea.  In  a  1-  to 
2-per-cent.  solution  it  finds  favor  as  an 
injection  for  gonorrhoea. 

Permanganate  solutions  should  not  be 
injected  into  gunshot  wounds  of  the  ab- 
domen, or  into  abscesses  connected  with 
the  peritoneal  cavity,  as  they  are  some- 
times irritating  or  even  caustic.  Glyc- 
erin should  not  be  added  to  perman- 
ganate solutions,  as  it  is  incompatible, 
and  forms  a  violent  explosive. 

C.  Sumner  Witherstixe, 

Philadelphia. 

MANIA.    See  Insanity. 

MANIA  A  POTTJ.    See  Alcoholism. 

MASTITIS.    See  Mammary  Gland. 

MASTOID  DISEASE.  Sec  Cerebral 
Abscess,  External  Ear,  and  Internal 
Ear. 

MEASLES. — From  an  old  English 
word  meaning  a  spot. 

Definition. — Measles — morbilli  or  ru- 
beola— is  an  acute,  infectious,  contagious 
disease  generally  met  with  iu  children. 

Symptoms. — Measles  runs  a  less  vari- 
able course,  as  a  rule,  than  does  scarlet 
fever  and  some  other  infectious  diseases. 
Very  mild  cases  sometimes  occur,  how- 
ever, while  the  disease  occasionally  runs 
a  very  severe  course.  In  rare  instances  a 
malignant  type  is  encountered.  Among 
115  cases  Carr  found  the  average  dura- 


MEASLES. 

tion  of  the  disease  when  uncomplicated 
to  be  twenty-six  days  from  the  prodromal 
symptoms  to  the  end  of  desquamation. 
The  period  of  incubation  of  measles  is 
about  twelve  days. 

Measles  usually  begins  gradually,  with 
feverishness,  sneezing,  coryza,  suffusion 
of  the  eyes,  and  photophobia.  Occasion- 
ally a  chill  followed  by  a  high  temper- 
ature is  the  initial  symptom.  Within 
twenty-four  hours  after  the  advent  of 
the  first  symptoms  a  cough  of  peculiarly 
hard  dry  character  appears  and  the  at- 
tack presents  all  the  symptoms  of  a 
catarrhal  cold.  The  coryza,  however,  is 
more  marked  than  that  of  an  ordinary 
cold.  The  fever  often  falls  somewhat 
after  the  first  day;  a  fact  which  may 
throw  the  physician  off  his  guard.  The 
coryza  and  cough,  however,  do  not  cor- 
respondingly diminish  with  the  fall  of 
the  temperature,  but  usually  increase. 
The  eruption  appears  on  the  side  of  the 
face  and  is  usually  first  seen  on  the  after- 
noon of  the  fourth  day  and  is  accom- 
panied by  increased  fever.  The  eruption 
may  appear  as  early  as  the  second  day, 
particularly  in  young  children,  and  is, 
in  rare  instances,  delayed  to  the  fifth  or 
sixth  day.  Drowsiness  is  not  uncom- 
mon during  the  stages  of  invasion,  but 
there  are  no  characteristic  constitutional 
symptoms. 

During  the  stage  of  invasion  and  be- 
fore the  anatomical  changes  are  noticed 
on  the  surface  of  the  body  an  eruption 
will  he  found  upon  the  velum  palati, 
which  constitutes  the  surest  sign  of  the 
affection.  Tyler  (Amer.  Jour,  of  Obstet- 
rics, Aug.,  '88). 

The  initial  fever,  or  catarrhal  stage, 
varies  to  an  equal  extent  with  the  incu- 
bation period;  out  of  193  cases  in  which 
this  was  noted,  12  had  no  premonitory 
symptoms,  the  rash  being  the  first  sign 
of  illness;  41  were  affected  only  one  day, 
29  two  days,  .1.")  three  days,  35  four  days, 
and  21  from  five  days  to  a  week  before 

4—34 


SYMPTOMS.  599 

the  eruption  appeared.  In  one  case  there 
was  a  period  of  three  days  of  giddiness, 
with  a  subnormal  temperature,  followed 
by  a  measles-rash.  J.  G.  Carstairs  (Aus- 
tralian Med.  Jour.,  July  16,  '93). 

Measles  give  rise  to  a  mild,  pultaceo- 
erythematous  stomatitis:  this  may  pre- 
cede exanthem,  always  accompanies  it, 
and  disappears  with  it.  It  is  insidious 
and  latent,  and  serves  as  means  of  diag- 
nosis in  doubtful  cases  (measles  or  ru- 
beola). Comby  (Le  Bull.  Med.,  Nov.  24, 
'95). 

Literature  of  '96-'97-'98. 

Measles  may  have  a  premonitory  rash. 
These  eruptions  vary  in  character,  being 
scarlatiniform,  morbilliform,  and  erysi- 
pelatous. They  may  even  resemble  red 
miliaria.  The  erythemata  generally  ap- 
pear about  the  second  day  of  the  period 
of  invasion,  and  disappear  before  the 
measles  eruption.  Robet  (Jour,  de  Med., 
Sept.  10,  '96). 

Koplik  has  recently  described  a  symp- 
tom which  he  believes  to  be  of  great 
value  in  making  an  early  diagnosis  of 
measles.  On  the  first  day  of  invasion  he 
has  found  that  an  examination  of  the 
buccal  mucous  membrane  in  a  good  light 
will  reveal  a  scattered  eruption  consist- 
ing of  small,  irregular  spots  of  bright- 
red  color,  in  the  centre  of  each  of  which 
is  a  minute  bluish-white  speck.  This  he 
regarded  as  pathognomonic  of  measles. 
Carr  and  other  writers  have  recently  ex- 
pressed a  belief  in  this  symptom. 

Literature  of  '96-'97-'98. 

Diagnostic  importance  of  the  bluish- 
white  spots  upon  the  mucosa  of  the 
cheeks,  signalized  by  Koplik  as  a  con- 
stant phenomenon  of  the  period  of  in- 
cubation, confirmed  by  the  examination 
of  50  morbillous  patients.  Lihman  (Med. 
Rec,  June  11,  '98). 

Koplik's  spots  found  45  times  in  52 
cases  of  measles,  and  in  another  epidemic 
31  times  in  32  cases.  A  good  illumination 
is  necessary  to  make  the  spots  visible. 
The  spots  scarcely  ever  coalesce,  and  the 
rash  can  easily  be  differentiated  from 


530  MEASLES.  SYMPTOMS. 


other  affections  of  the  mucous  mem- 
brane. It  somewhat  resembles  thrush, 
but  is  distinguished  from  this  by  the 
color  and  the  roundish  shape  of  the  erup- 
tion. They  cannot  be  wiped  off,  but  the 
whitish  spots  can  be  removed  with  for- 
ceps without  giving  rise  to  pain  or  bleed- 
ing. Microscopically  examined,  they 
consist  of  thick  layers  of  buccal  epithe- 
lium, partly  fatty  degenerated.  Koplik's 
spots  were  seen  in  measles  only;  they 
were  absent  in  nine  cases  of  rubeola. 
Slawyk  (Deut.  med.  Woch.,  No.  17,  '98). 

The  temperature  will  occasionally  be 
found  at  103°  or  104°  on  the  first  day, 
but  it  is  usually  not  above  102°.  The 
fever  does  not  ordinarily  range  as  high 
in  measles  as  in  scarlet  fever.  Not  infre- 
quently after  a  sharp  rise  on  the  first  day 
the  temperature  falls  on  the  two  follow- 
ing days,  but  increases  as  the  eruption 
appears  and  reaches  its  height  on  the  sec- 
ond day  of  the  eruption.  From  that  time 
it  gradually  falls,  and  becomes  normal 
between  the  seventh  and  ninth  days  of 
the  disease.  Not  infrequently  there  is  a 
sudden  fall  on  the  sixth  or  seventh  day, 
forming  almost  a  crisis.  The  fall  of  the 
temperature  after  the  initial  rise  on  the 
first  day  is  sometimes  so  decided  as  to 
lead  to  error  in  diagnosis.  The  possi- 
bility of  such  a  fall  is  always  to  be  con- 
sidered. The  fever  and  other  constitu- 
tional symptoms  are  usually  at  their 
height  when  the  eruption  has  reached  its 
fullest  development  on  the  fifth  or  sixth 
day  of  the  disease. 

In  a  number  of  cases  of  measles  com- 
plete absence  of  fever  noticed.  Monte- 
fusco  (Revue  Mens,  des  Mai.  de  l'En- 
fance,  Aug.,  '88). 

In  measles  the  temperature  does  not 
keep  up  quite  so  long  as  the  eruption 
lasts,  in  this  point  differing  from  scarlet 
fever.  J.  T.  Whittaker  (Ohio  Med.  Jour., 
Nov.,  '93). 

Case  of  hyperpyrexia  in  measles,  oc- 
curring in  an  infant  19  months  old.  The 
temperature  reached  109°  F.  and  re- 
mained there  for  an  hour  and  a  half; 


then  it  gradually  stopped.  The  child 
died  on  the  following  day.  J.  J.  Brachio 
(Indian  Med.  Bee,  June,  '92). 

Literature  of  '96-'97-'98. 

Case  of  a  child  of  16  months  who  de- 
veloped a  temperature  of  107°  F.  during 
the  premonitory  symptoms  of  measles. 
Four  days  later  the  temperature  sud- 
denly rose  to  110°  F.  Stimulation  with 
the  application  of  a  modified  cold  pack 
brought  the  temperature  down  to  97° 
in  three-quarters  of  an  hour;  convulsions 
followed,  occurring  several  times  during 
the  next  12  hours;  subsequently,  the 
condition  improved  and  the  child  grad- 
ually recovered.  B.  H.  A.  Hunter  (Brit. 
Med.  Jour.,  Apr.  30,  '98). 

The  rash  usually  appears  on  the  after- 
noon of  the  fourth  day,  but  in  some  cases 
is  seen  on  the  third  day  and  in  others  is 
j  delayed  until  the  fifth  day.  It  is  first 
seen  on  the  temples  and  sides  of  the  face, 
on  the  neck,  or  behind  the  ears.  "When  it 
first  appears  it  commonly  consists  of 
small  red  spots  having  no  strictly  char- 
acteristic appearance.  They  rapidly  in- 
crease in  size  and  form  small  macules  or 
very  slightly  elevated  papules  on  a 
slightly-reddened  base  with  normal  skin 
between.  They  are  circular  or  crescentic 
in  shape,  and,  being  hyperremic  in  na- 
ture, disappear  on  pressure. 

As  the  eruption  develops  it  tends  to 
become  confluent  in  places,  particularly 
on  the  face,  where  it  assumes  a  blotched 
appearance.  There  is  usually  a  certain 
amount  of  oedema,  particularly  about  the 
cheeks  and  eyes,  which  farther  tends  to 
change  the  appearance  of  the  patient. 
The  eruption  usually  reaches  its  height 
at  its  first  site  of  appearance  at  the  end 
of  thirty-six  hours;  it  remains  stationary 
for  about  two  days,  and  then  rapidly 
fades  away.  It  extends  over  the  body 
somewhat  slowly,  appearing  on  the  tmnk 
and  limbs  on  the  second  day. 

The  wrists  and  backs  of  the  hands  are 


MEASLES.    SYMPTOMS.  531 


commonly  the  points  to  be  last  involved. 
When  at  its  height  in  these  places, 
the  rash  is  sometimes  partially  faded  on 
the  face  and  neck.  On  the  first  day  the 
spots  form  simple  macules,  but  later  they 
become  flat  papules  that  can  be  readily 
felt  by  the  finger  and  are  sometimes 
almost  shotty  to  the  touch.  The  rash 
commonly  presents  its  most  typical  ap- 
pearance on  the  chest. 

The  typical  rash  of  measles  is  fre- 
quently accompanied  by  miliary  vesicles 
and  in  rare  cases  petechiae  appear.  Oc- 
casionally the  rash,  instead  of  assuming 
the  usually  hypergemic  form,  becomes 
distinctly  hsemorrhagic.  This  may  occur 
in  limited  areas  or  may  extend  over  the 
whole  body.  In  the  latter  case  it  pre- 
sents the  type  known  as  "black  measles," 
a  condition  extremely  rare  in  private 
practice.  It  indicates  a  severe  form  of 
the  disease,  but  is  not  as  generally  fatal 
as  is  popularly  supposed.  The  spread  of 
the  eruption  is  sometimes  extremely 
rapid,  the  whole  body  being  covered  in  a 
few  hours,  but  this  is  rare.  In  other  rare 
instances  the  rash  is  so  slight  and  of  such 
short  duration  as  to  be  almost  over- 
looked. The  constitutional  symptoms  in 
such  cases  are,  as  a  rule,  correspondingly 
mild.  Occasionally  in  malignant  cases, 
marked  by  sudden  and  severe  initial 
symptoms,  the  rash  scarcely  makes  its 
appearance  or  is  greatly  delayed. 

No  disease  is  like  measles  save  rotheln; 
and  this  can  be  easily  distinguished,  if 
the  severity  of  the  catarrhal  symptoms, 
the  nature  of  the  cough,  the  appearances 
of  the  fauces,  and  the  high  febrile  move- 
ment at  the  height  of  the  eruption  be 
recognized.  Tyler  (American  Jour,  of 
Obstet.,  Aug.,  '88). 

Literature  of  '96-'97-'98. 

All  causes  which  can  provoke  an  ob- 
struction of  the  local  or  general  cutane- 
ous circulation  may  produce  an  ecchy- 
motic    form    of    morbillous  eruption. 


Diseases  of  the  larynx  associated  with 
dyspnoea,  and  especially  whooping-cough, 
may  be  mentioned  as  the  chief  of  these. 
Albert  Rouger  (These  de  Paris,  '96). 

Enanthem  described  as  characteristic 
of  German  measles.  This  is  a  macular, 
distinctly  rose-red  eruption  upon  the 
velum  of  the  palate,  the  uvula,  extend- 
ing to  but  not  on  to  the  hard  palate. 
These  spots  are  arranged  irregularly,  not 
crescentically,  are  the  size  of  large  pin- 
heads,  and  are  very  little  elevated  above 
the  level  of  the  mucous  membrane.  It 
is  very  short  lived  and  fades  away 
within  the  first  twenty-four  hours.  It  is 
the  same  eruption  found  upon  the  skin. 
Forchheimer  (Pediatrics,  July  1,  '98). 

The  constitutional  symptoms  reach 
their  height  during  the  stage  of  eruption, 
j  being  usually  at  a  maximum  on  the  sixth 
da}'  of  the  disease.  They  then  remain 
stationary  for  about  two  days,  when  the 
fever  abates  and  all  the  symptoms  begin 
to  subside.  This  sometimes  occurs  so 
suddenly  on  the  sixth  or  seventh  day  as 
to  form  a  crisis.  This,  however,  is  not 
the  rule. 

During  the  height  of  the  disease  the 
patient  presents  a  very  characteristic  ap- 
pearance. The  face  is  covered  by  a 
patchy  eruption  and  is  swelled  and 
cedematous;  the  eyes  are  red  and  sensi- 
tive to  the  light  and  are  filled  with  a 
mucus  or  muco-purulent  secretion;  the 
nose  is  swelled  and  discharges  a  similar 
secretion;  there  is  a  dry,  metallic,  and 
very  troublesome  cough;  the  tongue  is 
coated;  the  appetite  is  completely  lost; 
the  bowels  are  frequently  relaxed;  the 
child  lies  in  a  heavy  and  stupid  condi- 
tion, but  is  restless  and  irritable  when 
disturbed.  The  glands  at  the  angle  of 
the  jaw  are  frequently  enlarged,  and  not 
infrequently  the  post-cervical  glands, 
also. 

As  the  fever  subsides  the  cough  rapidly 
changes  its  character,  becoming  looser 
and  less  irritating.    It  frequently  disap- 


532  MEASLES.  SYMPTOMS. 


pears  within  a  week,  but  sometimes  the 
evidences  of  bronchitis  continue,  and  the 
cough  proves  a  troublesome  symptom 
for  several  weeks.  In  most  cases  the 
photophobia  subsides  rapidly,  but  the 
eyes  are  prone  to  remain  weak  and 
watery.  If  strong  light  is  admitted  too 
soon  a  mild,  but  very  troublesome  and 
persistent,  form  of  conjunctivitis  may  re- 
sult. Other  symptoms  usually  subside 
rapidly;  the  child  becomes  brighter  and 
less  irritable;  the  appetite  returns,  and 
evidences  of  illness  soon  disappear. 

Desquamation.  —  Desquamation  be- 
gins as  soon  as  the  eruption  has  faded, 
and  follows  the  order  of  its  appearance. 
It  rarely  continues  more  than  ten  days 
in  any  given  area,  and  may  be  of  much 
shorter  duration.  It  is  most  intense 
where  the  eruption  has  been  most  in- 
tense. It  occurs  in  fine  branny  scales 
quite  unlike  the  lamellar  desquamation 
of  scarlet  fever.  It  is  often  so  slight  as 
to  be  completely  overlooked,  particularly 
when  inunctions  of  the  skin  have  been 
carefully  used.  Desquamation  is  usually 
completed  in  from  twenty  to  twenty-four 
days  after  the  onset  of  the  disease. 

Irregular  Forms. — Measles  is  capable 
of  assuming  very  irregular  and  atypical 
forms.  Such  irregular  types  are  most 
common  in  children  under  three  years. 
Nevertheless,  in  a  given  number  of  cases 
a  much  larger  proportion  of  measles  cases 
will  run  a  typical  or  regular  course  than 
will  a  similar  number  of  cases  of  scarlet 
fever. 

In  an  epidemic  of  423  cases,  only  123 
were  of  the  regular  type;  103  were  of 
the  malignant  type,  complicated  with 
sonic  other  disease,  and  furnished  7  of 
the  fatal  eases.  The  remaining  200  eases 
were  of  the  hsemorrhagic  form.  The  only 
symptoms  present  in  absolutely  all  the 
eases,  of  whatever  type,  were  rise  of 
temperature  and  eruption.  The  catar- 
rhal symptoms  were  entirely  absent  in 
about    5    per   cent,    of   the   eases.  The 


mouth-rashes  of  Guersant  and  Blache 
and  of  Girard  were  present  in  only  about 
25  per  cent.  C.  J.  Edgar  (Canada  Med. 
Kec.,  Dec,  '92). 

Mild  Type. — The  disease  may  be  ex- 
tremely mild,  the  eruption  being  faint, 
the  fever  slight,  and  all  the  symptoms 
mild.  Such  cases  present  no  variation 
from  the  usual  type  except  that  of  mild- 
ness in  degree.  Although  the  catarrhal 
symptoms  may  be  slight,  the  diagnosis 
of  morbilli  sine  catarrho  should  be  made 
with  extreme  hesitation. 

Case  of  atypical  measles  in  which  there 
was  sudden  onset,  absence  of  coryza,  ery- 
thematous sore  throat,  and  scarlatiniform 
eruption.  J.  C.  Wilson  (Med.  and  Surg. 
Reporter,  Jan.  17,  '91). 

Case  of  measles  in  which  all  catarrhal 
symptoms  were  absent.  J.  B.  Harris 
(Lancet,  Feb.  21,  '91). 

Literature  of  '96-'97-'98. 

Case  of  a  girl  who  had  measles  for  the 
first  time  at  eight  years,  and  a  second 
attack  two  years  later. 

In  the  first  attack  the  skin  was  se- 
verely aflfected,  but  the  catarrhal  symp- 
toms were  extremely  mild.  In  the  sec- 
ond attack  the  throat  symptoms  were 
severe  and  characteristic,  but  the  exan- 
them  did  not  appear  until  two  or  per- 
haps three  days  after  the  usual  time,  as 
indicated  by  the  other  symptoms,  was 
imperfectly  developed,  and  soon  faded. 
Gottstein  (Munch,  med.  YVoeh..  No.  13. 
'96). 

Severe  Type. — A  severe  form  is 
sometimes  seen,  marked  by  unusually 
high  temperature,  intense  eruption,  and 
severity  of  all  the  symptoms.  Excepl  in 
young  children,  the  uncomplicated  dis- 
ease, even  when  of  severe  type,  is  rarely 
fatal.  But  it  should  not  he  forgotten 
that  a  temperature  that  reaches  an  un- 
usually high  point  or  continues  unabated 

!  as  the  eruption  fades  is  usually  due  to 
some  complication,  commonly  pulmo- 

I  nary.    Any  marked  variation  from  the 


MEASLES. 

usual  type  demands  particular  attention, 
for  it  commonly  indicates  a  complication. 

Malignant  Type.  —  Malignant 
measles,  marked  by  intense  and  over- 
whelming symptoms  from  the  outset,  is 
fortunately  rare  outside  of  institutions. 
The  same  is  true  of  hsemorrhagic,  or 
black,  measles. 

Case  of  malignant  measles  in  an  adult, 
simulating  typhus  fever,  purpura  fulmi- 
nans,  cerebrospinal  fever,  and  variola. 
J.  C.  Wilson  (N.  Y.  Med.  Jour.,  Aug.  4, 
•94). 

Rubeola  tropica  is  a  specific  eruptive 
fever,  the  primary  rose-red  rash  appear- 
ing on  the  face  and  neck  on  the  second 
day  of  the  illness;  the  second  rash, 
miliary  and  papular,  on  the  body,  face, 
and  occasionally  on  the  limbs,  on  the 
fourth  day.  The  third  rash — of  small, 
coalescent  wheals — appears  on  the  arms 
and  legs,  or  legs  only,  on  the  sixth  day, 
when  the  fever  subsides.  The  more  se- 
vere form  of  the  disease  chiefly  attacks 
adults.  It  is  epidemic,  contagious,  but 
seldom  associated  with  catarrh  or  des- 
quamation, and  characterized  by  the  in- 
tensity of  the  pains  in  the  back,  head, 
and  orbit,  on  the  third  and  fourth  days 
of  the  illness.  The  period  of  incubation 
is,  in  ascertained  cases,  under  seven  days. 
For  three  days  after  the  disappearance 
of  the  rash  the  patient  can  eat  but  little, 
and  is  so  weak  that  he  feels  disinclined 
to  attempt  to  walk.  Soreness  is  experi- 
enced in  the  back  and  sides,  but  the 
headache  and  pain  in  the  orbit  are  gone, 
although  giddiness  is  complained  of.  A 
marked  symptom  in  all  is  complete  ab- 
sence of  taste.  A  further  sequel  is  a  sub- 
cutaneous haemorrhage  from  the  capil- 
laries of  the  legs.  James  Cantlie  (Lan- 
cet, June  25,  '92). 

Relapse  in  measles  is  extremely  rare 
and  is,  in  fact,  of  doubtful  occurrence. 
A  secondary  rise  in  temperature  after  a 
normal  fall  indicates  a  complication. 

Literature  of  '96-'97-'98. 

Eleven  cases  of  measles  with  relapses 
were  seen  in  two  epidemics  at  about  the 
same  time.   From  the  two  series  of  cases 


ETIOLOGY.  533 

it  would  appear  that  overcrowding  was 
more  probably  the  cause  of  relapse  than 
increased  virulence  of  the  germ.  A. 
Chauffard  and  G.  H.  Lemoine  (Bull. 
Med.,  Jan.  1,  8,  '96). 

Two  clear  cases  of  recurrence  in 
measles  seen.  Sevestre  (Bull.  Med.,  Jan. 
1,  8.  '96). 

Of  more  than  700  cases  of  measles,  not 
a  single  case  of  recurrence  or  relapse 
seen.    Comby  (Bull.  Med.,  Jan.  1,  8,  '96). 

Etiology. — Measles  is  doubtless  due  to 
bacterial  action,  but  no  specific  micro- 
organism has  yet  been  isolated. 

Priority  claimed  in  the  discovery  of 
the  measles  bacillus,  prepared  specimens 
of  them  having  been  shown  as  early  as 
May,  1878,  at  a  meeting  of  the  London 
Pathological  Society.  P.  Murray  Braid- 
wood  (Lancet,  Apr.  30,  '92). 

Bacillus  considered  the  specific  organ- 
ism of  measles  discovered  in  fourteen 
cases  of  the  disease,  in  the  blood  as  well 
as  in  the  sputum,  and  the  nasal  and 
conjunctival  secretions. 

It  is  very  variable  in  size,  sometimes 
as  long  as  one-half  the  diameter  of  a  red 
blood-corpuscle,  sometimes  quite  small, 
with  the  appearance  of  diplococci.  Canon 
and  Pielicke  (Brit.  Med.  Jour.,  Apr.  23, 
'92). 

Blood  in  24  severe  cases  of  measles  ex- 
amined according  to  the  method  detailed 
by  Canon  and  Pielicke,  with  entirely 
negative  results.  Albert  Josias  (La  Med. 
Mod.,  June  2,  '92). 

Bacillus  personally  observed  as  exist- 
ing in  the  blood  in  measles.  The  bacilli 
in  the  blood  vary  in  length  from  one-half 
micromillimetre  to  the  diameter  of  a 
red  blood-corpuscle,  and  in  cultures  grow 
into  long  threads.  They  stain  well  with 
all  the  aniline  dyes,  and  in  the  longer 
forms  a  part  of  the  protoplasm  often  re- 
mains unstained.  They  lose  their  stain 
by  Gram's  method.  They  grow  best  in 
bouillon  or  sterile  serous  fluid  from  the 
abdominal  cavity,  in  which  a  whitish, 
fairly  heavy  sediment  is  formed,  which 
in  older  cultures  becomes  yellowish- 
gray.  The  cultures  have  no  character- 
istic odor.  Rabbits  were  always  immune 
to  the  bacteria.  Mice  died  from  septi- 
caemia three  to  four  days  after  inocula- 


534  MEASLES.  ETIOLOGY. 


tion  with  small  quantities  of  the  culture, 
the  bacilli  being  obtained  again  in  pure 
cultures  from  the  liver  and  spleen. 

The  bacillus  believed  to  be  the  specific 
cause  of  measles.  Joseph  Czajkowski 
(Centralb.  f.  Bakt.  u.  Parasit.,  Nos.  17 
and  18,  '95). 

The  vitality  of  the  germ  is  evidently 
small,  though  it  must  be  extremely  dif- 
fusible, for  measles  is  the  most  contagious 
of  the  infectious  diseases,  except  small- 
pox. Its  occurrence  is  uncommon  under 
six  months,  but  above  that  age  every 
child  who  has  not  already  had  it  may  be 
expected  to  contract  it  upon  exposure. 

Literature  of  '96-'97-'98. 

Case  of  infant  born  on  the  day  when 
the  mother  exhibited  the  morbillary 
rash,  and  at  the  time  of  birth  had  nasal 
catarrh,  conjunctivitis,  and  cough.  When 
three  days  old  the  eruption  was  out  over 
the  whole  body,  the  temperature  was 
raised,  and  the  whole  clinical  picture  of 
measles  was  presented.  Recovery  oc- 
curred after  the  lapse  of  six  days.  A. 
Bartsch  (Ugeskrift  for  Laeger,  No.  48, 
'96). 

Case  of  measles  in  an  infant,  eruption 
appearing  thirteen  days  after  delivery. 
Possible  infection  at  birth.  Carstairs 
Douglas  (Brit.  Med.  Jour.,  May  7,  '98). 

Case  of  infant  seized  one  week  after 
birth  with  measles.  Other  children  in 
the  house  had  been  suffering  from  the 
disease,  and  it  is  believed  that  infection 
occurred  at  birth.  F.  C.  Fitz-Gerald 
(Brit.  Med.  Jour.,  Oct.  1,  '98). 

Adults  are  rather  more  susceptible  to 
it  than  to  the  other  infectious  diseases. 
Measles  is  endemic  in  all  large  towns,  but 
at  intervals  it  becomes  epidemic  and 
spreads  over  a  wide  area  before  it  expends 
itself.    Sex  is  not  a  predisposing  factor. 

Sources  of  Infection. — Measles  is 
transmitted  by  direct  contact,  but  the 
area  of  contagion  is  large.  Although  in- 
termediate contagion  may  occur,  it  is 
comparatively  rare.  The  infectious 
power  of  the  poison  is  quickly  lost,  so 


that  sick-rooms  very  soon  become  safe 

for  occupancy. 

The  following  conclusions  deduced 
from  study  of  three  distinct  epidemics 
of  measles:  1.  Measles  are  spread  by 
actual  contact  with  the  materies  morbi. 

2.  A  case  in  the  stage  of  incubation  may 
inoculate   those   who   are  unprotected. 

3.  It  cannot  be  carried  by  a  protected 
person  coming  from  a  case  of  the  dis- 
ease to  a  susceptible  person.  4.  It  does 
not  spread  through  the  atmosphere.  5. 
Strict  quarantine  will  prevent  it.  V.  M. 
Reichard  (Therap.  Gaz.,  July  1G,  '88). 

Following  conclusions  bear  on  the  in- 
cubation and  contagiousness  of  measles: 
1.  The  germ  of  rubeola  does  not  remain 
in  a  locality  from  which  those  who  have 
suffered  from  the  disease  have  gone 
away.  Hence,  disinfection  of  the  bed 
and  furniture  is  unnecessary.  2.  Con- 
tagion is  always  direct,  from  person  to 
person.  3.  Incubation  is  shorter  in  the 
intense  than  in  the  mild  forms.  It 
usually  lasts  from  12  to  18  days,  but 
may  last  21  days.  4.  The  power  of  the 
contagion  is  such  that  in  a  favorable 
medium  it  attacks  all  who  are  suscep- 
tible to  it.  5.  Contagion  is  possible  3 
or  4  days  before  an  eruption  is  evident. 
6.  Broncho-pneumonia  is  a  secondary  ad- 
ditional infection,  but  may  co-exist  with 
the  rubeola  and  manifest  a  mixed  infec- 
tion. Bard  (Revue  d'Hygiene  et  de 
Police  Sanitaire,  May  20,  '91). 

It  is  possible  that  contagium  may  be 
conveyed  by  the  breath;  but  it  is  certain 
that  it  resides  in  the  sputa  and  the  dis- 
t  charges  from  the  nose  and  eyes. 

Literature  of  '96-'97-'9&. 

The  nasal  fossae  and  the  throats  of 
monkeys  touched  with  mucus  obtained 
from  children  with  measles  in  the  first 
or  second  day  of  the  eruption.  Three 
out  of  eight  animals  presented  local  and 
general  symptoms  resembling  those  seen 
in  human  measles.  Josias  (La  Semaine 
Med.,  Mar.  9,  598). 

If  the  contagion  resides  in  the  des- 
quamation scales,  it  is  far  less  potent 
!  than  is  the  poison  carried  by  the  dosqua- 


MEASLES.    INFECTION.  PATHOLOGY. 


535 


mation  of  scarlet  fever.  The  disease  may 
be  conveyed  by  clothing  or  it  may  be 
contracted  by  a  susceptible  person  enter- 
ing a  room  recently  left  by  a  measles 
patient. 

There  is  no  law  of  periodicity  in 
measles  epidemics.  The  measles  con- 
tagion must  have  its  origin  in  some  kind 
of  clothing  which  has  been  worn  by,  or 
has  come  into  contact  with,  an  infective 
person.  The  spread  of  measles  appears 
to  be  influenced  by  the  time  of  year; 
the  number  diminishes  with  the  approach 
of  warm  weather.  Moller  (Archiv  f. 
Kinderh.,  vol.  xxi). 

Incubation". — The  period  of  incuba- 
tion ranges  from  9  to  21  days.  Holt 
found  it  to  be  between  11  and  14  days  in 
66  per  cent,  of  144  carefully-observed 
cases.  I  have  repeatedly  seen  the  initial 
symptoms  appear  12  days  after  exposure. 
From  all  the  evidence  available  it  would 
seem  that  12  days  is  the  most  common 
period  of  incubation. 

The  incubation  period  varies  from  8  to 
9  days  to  15  and  16  days  in  different 
cases.  Measles  are  extremely  contagious 
before  the  rash  appears.  J.  J.  Eyre 
(Brit.  Med.  Jour.,  Feb.  23,  '89). 

Case  of  measles  in  which  the  period  of 
incubation  was  27  days.  P.  Trekaki 
(Paris  Med.  vol.  xiv,  No.  49,  '89). 

In  several  hundred  cases  of  measles 
the  period  of  incubation  was  found  to  be 
from  twelve  to  eighteen  days.  J.  G.  Car- 
stairs  (The  Scalpel,  July  15,  '93). 

Incubation  of  measles  is  almost  uni- 
formerly  thirteen  or  fourteen  days.  W.  F. 
Lockwood  (Archives  of  Pediatrics,  June, 
'93). 

Infection.  —  Measles  may  be  conta- 
gious from  the  first  appearance  of  the 
catarrhal  symptoms,  authentic  cases  be- 
ing recorded  in  which  the  disease  was 
transmitted  four  days  before  the  eruption 
appeared.  It  is  most  contagious,  how- 
ever, when  the  disease  is  at  its  height. 
The  contagiousness  diminishes  as  the 
active  symptoms  subside,  and  is  slight 
during  the  stage  of  desquamation.  Ex- 


cept in  complicated  cases,  in  which  the 
catarrhal  symptoms  are  usually  pro- 
longed, the  period  of  infection  is  not 
over  twenty-eight  days. 

Rubeola  is  very  contagious  during  the 
period  of  invasion;  continues  to  be  so, 
but  at  a  less  degree,  during  the  eruptive 
period;  and  ceases  at  its  termination. 
Transmission  is  usually  effected  by  the 
circumambient  air.  Contagion  by  a  vis- 
itor or  by  objects  which  the  patient 
touches  is  rare.  Sevestre  (Le  Prog. 
Med.,  Mar.  2,  '89). 

Pathology. — In  uncomplicated  measles 
the  lesions  are  confined  to  the  skin  and 
the  mucous  membranes  of  the  conjunc- 
tivae, nose,  pharynx,  larynx,  and  the 
larger  bronchial  tubes.  The  morbid 
changes  of  the  skin  are  those  of  acute 
hyperemia;  on  the  mucous  membranes 
they  are  those  of  acute  catarrh.  In  com- 
plicated cases  pseudomembranous  inflam- 
mation may  occur.  Death  rarely  results 
from  the  simple  disease,  but  rather  from 
the  complications,  which  will  be  con- 
sidered later.  The  complications  are  due 
to  mixed  infection,  the  germ  most  com- 
monly present  being  the  staphylococcus. 
The  streptococcus  is,  however,  frequently 
present,  and,  as  a  rule,  causes  more  seri- 
ous lesions  than  those  of  the  staphylo- 
coccus. The  mucous  membranes  are 
rendered  very  susceptible  by  measles  to 
these  germs.  As  they  are  invariably 
present  in  the  wards  of  hospitals,  the 
disease  in  such  institutions  is  always"  a 
dreaded  one,  for  it  is  prone  to  be  com- 
plicated. 

In  post-mortem  examinations  of  pa- 
tients dying  from  measles,  a  general  in- 
fection by  streptococci  found.  Le  Dantec 
(Gaz.  Hebdom.  des  Sci.  Med.  de  Bor- 
deaux, June  19,  '92). 

Attention  called  to  manifestation  of 
subacute  septicemic  infection  in  very 
young  children.  It  is  attributed  to  in- 
fection by  streptococci.  V.  Hutinel  and 
Paul  Claisse  (Revue  de  Med.,  May  10, 
'93). 


536 


MEASLES.    COMPLICATIONS  AND  SEQUELAE. 


Case  in  which  a  varioliform  eruption 
developed  in  a  case  recovering  from  an 
attack  of  measles.  An  eruption  having 
same  structure  as  pustules  of  variola 
may  occur  without  involvement  of  epi- 
dermis, but  simply  through  presence  of 
bacteria  in  the  capillaries  of  papillary 
body  ;  thrombosis  of  vessels  of  the  skin 
may  occur  without  haemorrhage.  Unna 
(Univ.  Med.  Jour.,  Oct.,  '95). 

Literature  of  '96-'97-'98. 

Case  of  gangrene  of  the  lung  in 
measles.  In  the  gangrenous  focus  there 
were  found  streptococci,  a  bacillus  re- 
sembling the  Klebs-Lcefner  bacillus,  and 
bacilli  resembling  morphologically  the 
streptothrix  and  a  large,  putrefactive 
germ.  Mery  and  Lorrain  (Soc.  Anat.  de 
Paris,  Mar.,  '97). 

Complications    and    Sequelae.  —  The 

most  common  and  serious  complications 
of  measles  are  broncho-pneumonia,  mem- 
branous laryngitis,  and  otitis;  the  most 
common  sequelae  are  tuberculosis  and 
conjunctivitis. 

Bronchial  catarrh  is  an  essential  part 
of  measles,  but  it  is  very  easy  for  the 
inflammation  to  extend  from  the  smaller 
bronchi  to  the  alveoli,  thus  transforming 
a  normal  condition  into  a  most  serious 
complication,  —  namely,  broncho  -  pneu- 
monia. The  younger  the  child,  the 
greater  is  this  danger.  It  occurs  chiefly 
in  children  under  three  years,  and  is 
comparatively  rare  in  children  over  four 
years.  It  is  very  common  in  institu- 
tions and  renders  measles  the  most 
dreaded  of  all  epidemic  diseases  in  in- 
fant hospitals,  diphtheria  being  no  ex- 
ception to  the  rule.  In  a  recent  epi- 
demic of  measles  in  the  Infants'  Hos- 
pital of  New  York  every  case  in  children 
under  eighteen  months  was  compli- 
cated by  broncho-pneumonia  or  croup, 
and  80  per  cent.  died.  The  pneumonia 
usually  made  its  appearance  soon  after 
the  eruption  reached  its  height,  but  de- 


veloped in  a  few  cases  during  the  stage 
of  invasion,  the  disease  being  regarded  in 
two  instances  as  simple  broncho-pneu- 
monia until  the  eruption  suddenly  ap- 
peared. According  to  Holt,  10  per  cent, 
of  all  cases  are  complicated  by  broncho- 
pneumonia. He  agrees  with  Henoch  that 
a  certain  amount  of  pneumonia  is  found 
at  autopsy  in  almost  every  fatal  case. 
Carr  found  it  clinically  twenty-one  times 
among  one  hundred  and  fifteen  hospital 
patients. 

The  pneumococcus  and  streptococcus 
are  met  with  in  the  saliva  of  children 
suffering  from  measles  with  much  greater 
frequency  than  is  the  case  in  health. 
Broncho-pulmonary  complications  in  the 
course  of  measles  only  occur,  with  but 
rare  exceptions,  in  children  in  whom  the 
saliva  contains  the  pneumococcus  and 
streptococcus;  therefore,  during  the  prog- 
ress of  a  case  of  measles  the  most  rigor- 
ous attention  should  be  paid  to  buccal 
antisepsis.  H.  Mery  and  P.  Boulloche 
(Eevue  Men.  des  Mai.  de  l'Enfance,  Apr., 
'91). 

Infectious  erythema  following  the 
eruption  of  measles  (two  to  sixteen 
days),  generally  observed  in  cases  com- 
plicated with  purulent  bronchitis  or 
broncho-pneumonia  with  infection  by 
streptococci.  When  associated  with 
broncho-pneumonia,  death  very  rapid. 
Mussy  (Jour,  de  Med.  et  de  Chir.  prat., 
Apr.  10,  '93). 

Four  cases  of  measles  complicated  with 
muco-sanguineous  diarrhoea.  Children  in 
same  ward  and  almost  simultaneously  at- 
tacked: all  died  presenting  symptoms  of 
broncho-pneumonia.  At  autopsy,  ulcera- 
tions of  sigmoid  flexure  and  rectum 
analogous  to  those  of  true  dysentery. 
Meslay  and  Jolly  (Revue  Men.  des  Mai. 
de  l'Enfance,  Aug.,  '95). 

Lobar  pneumonia  is  an  occasional  com- 
plication of  measles  in  children  over  four 
years,  but  is  seldom  if  ever  found  under 
three  years.  Empyema  is  sometimes  a 
sequel  of  such  complicating  lobar  pneu- 
monia. The  signs  and  rational  symp- 
'  toms  of  either  form  of  pneumonia  com- 


MEASLES.    COMPLICATIONS  AND  SEQUELS. 


537 


plicating  measles  present  nothing  un- 
usnal. 

Case  of  subcutaneous  emphysema 
complicating  measles  in  the  absence  of 
any  violent  cough  or  any  known  injury. 
S.  W.  Kelley  (Therap.  Gaz.,  Jan.,  '91). 

Emphysema  of  the  subcutaneous  tissue 
in  case  of  a  child,  2  1/2  years  of  age,  who 
had  suffered  from  measles  for  six  weeks, 
with  much  coughing.  Felsenthal  (Ar- 
chiv  f.  Kinderh.,  B.  14,  H.  1,  2,  '91). 

Catarrhal  pharyngitis  is  an  essential 
part  of  measles;  pseudomembranous 
pharyngitis  sometimes  occurs  as  a  com- 
plication. Instead  of  invading  the  nose 
and  ears,  as  in  scarlet  fever,  it  shows  a 
strong  tendency  to  invade  the  larynx; 
but  croup  frequently  develops  without 
the  appearance  of  membrane  in  the  phar- 
ynx. 

Six  cases  of  croup  with  alarming  ste- 
nosis, 2  cases  of  dyspnoea  of  pulmonary 
origin,  1  case  of  broncho-pneumonia  with 
pyothorax,  3  cases  of  acute  delirium 
during  convalescence  from  measles  (all 
three  in  adults),  and  1  case  of  polyuria 
with  retention  for  twenty-two  days 
(without  paraplegia),  all  noted  as  com- 
plications of  measles.  H.  Audeoud  and 
M.  Jaccard  (Revue  Med.  de  la  Suisse 
Rom.,  Jan.  20,  '94). 

Laryngeal  cough,  due  to  punctate 
spots  and  shallow  ulcers  in  the  air- 
passages,  is  very  common  in  measles. 
The  symptoms  suggest  croup.  A.  Broth- 
ers (Jour,  of  Laryng.,  May,  '93). 

As  in  scarlet  fever,  the  pseudomem- 
branes  which  develop  during  the  height 
of  the  attack  are  usually  due  to  strepto- 
cocci, and  are,  therefore,  not  true  diph- 
theria. Those  which  develop  later  are 
usually  due  to  Klebs-Loeffler  bacilli  and 
are  true  diphtheria.  This  secondary 
streptococcic  disease,  however,  is  quite  as 
fatal  as  the  bacillary  disease.  Not  only 
is  the  child  in  imminent  danger  from 
laryngeal  complications,  but  it  is  almost 
certain,  also,  to  develop  broncho-pneu- 
monia, which  occurs  as  the  direct  result 
of  streptococcic  infection.    The  differ- 


ential diagnosis  between  true  and  false 
diphtheria  can  rarely  be  made  with  cer- 
tainty from  clinical  appearances  alone. 
Fortunately,  in  private  practice  both 
complications  are  rare  in  children  over 
four  years. 

Rapidly- fatal  so-called  pseudodiph- 
theria  may  supervene  in  measles  without 
affording  any  certain  diagnostic  clinical 
sign.  W.  F.  Lockwood  (Archives  of 
Pediatrics,  June,  '93). 

Klebs-Loeffler  bacilli  in  the  throats  of 
ten  out  of  twenty-eight  cases  of  measles. 
None,  save  one  case  requiring  intubation, 
showed  any  sequelae  or  further  mani- 
festations of  diphtheria.  R.  S.  Adams 
(Med.  Rec,  Sept.  29,  '94). 

Literature  of  '96-'97-'98. 

Case  of  association  of  measles  and 
diphtheria  in  the  same  subject.  M. 
Poulet  (N.  Y.  Med.  Jour.,  June  5,  '97). 

Otitis,  while  less  common  than  in 
scarlet  fever,  sometimes  occurs,  but  does 
not  usually  prove  so  serious.  Both  ears 
are  usually  involved,  but  the  disease  pre- 
sents in  its  symptoms  and  course  nothing 
worthy  of  particular  mention. 

Alterations  found  in  the  labyrinth  in 
measles  which  pertain  to  the  lymphatics 
and  the  blood-vessels.  In  the  former  the 
lymph  coagulates  and  the  cells  accumu- 
late; they  also  fill  up  the  semicircular 
canals  and  the  cochlea.  The  endo- 
thelium undergoes  fatty  degeneration. 
In  the  blood-vessels  the  destruction  is 
nearly  complete  in  the  Haversian  canals 
and  in  the  spiral  ligament.  The  muscles 
undergo  waxy  degeneration.  The  nerves 
become  gelatinous  and,  at  places,  entirely 
atrophied.  The  cells  of  Corti's  mem- 
brane are  also  similarly  degenerated. 
Notwithstanding  the  intensity  of  these 
lesions  and  the  frequency  of  auditory 
complications  in  measles,  permanent 
deafness  is  a  rare  sequence.  Moos 
(Amer.  Jour.  Med.  Sci.,  July,  '88). 

Tympanic  involvement  was  due  in  20. 1 
per  cent,  of  cases  to  measles.  The  otitis 
media  is  due,  not  so  much  to  direct  ex- 
tension of  inflammation  from  the  throat 


538 


MEASLES.    COMPLICATIONS  AND  SEQUELS. 


and  nose,  by  the  Eustachian  tube,  to  the 
middle  ear,  as  by  the  sealing  or  plugging 
of  the  mouth  of  the  Eustachian  tube  by 
the  retained  mucus  in  the  naso-pharynx, 
the  damming,  then,  of  mucus  in  the  ear, 
with  consequent  distension,  extravasa- 
tion, and  pain  in  the  ear, — all  favored  by 
the  recumbent  position.  Downie  (Brit. 
Med.  Jour.,  Nov.  24,  '94). 

Literature  of  '96-'97-'98. 

The  inflammatory  process  in  the  middle 
ear  in  measles  usually  runs  its  course 
without  subjective  and  often  without 
objective  symptoms,  and  only  now  and 
then  leads  to  spontaneous  perforation  of 
the  membrana.  The  ears  in  measles 
should  therefore  be  carefully  watched. 
A.  0.  Pfingst  (Pediatrics,  Feb.  1,  '98). 

Complete  anorexia  is  common  during 
the  febrile  stage.  Diarrhoea  is  of  fre- 
quent occurrence  and  may  be  so  severe 
as  to  prove  a  serious  complication.  It 
may  be  due  to  simple  intestinal  indiges- 
tion, or  it  may  be  the  evidence  of  entero- 
colitis. It  is  occasionally  so  severe  as  to 
prove  a  serious  complication. 

Febrile  albuminuria  is  not  infrequent 
in  cases  with  high  temperature,  but 
nephritis  is  very  rare. 

Fatal  case  of  uraemia  sequent  to 
measles.  S.  Zichy-Woinarski  (Australa- 
sian Med.  Gaz.,  Oct.  15,  '93). 

Nervous  symptoms,  excepting  the  oc- 
casional appearance  of  convulsions  at  the 
outset,  are  rare. 

Paralysis  following  measles  is  more 
frequent  in  the  female  than  the  male, 
and  more  frequent  in  children  than  in 
adults.  Bayle  (Revue  de  Ther.  Medico- 
Chir.,  Mar.  1,  '88). 

Paralysis  due  to  measles  is  not  as 
rare  as  is  commonly  believed.  There  are 
two  forms,  the  spinal  and  cerebral.  P.  A. 
Lop  (Centralb.  f.  klin.  Med.,  No.  50,  '93). 

Literature  of  '96-'97-'98. 

Case  of  ascending  myelitis  compli- 
cating measles.  Ellison  (Lancet,  Oct.  17, 
'96). 


Two  cases  of  mania  during  measles. 
Finkelstein  (Wratch,  No.  20,  '98). 

Case  of  mania  due  to  intestinal  septic 
absorption,  occurring  on  the  eighth  day 
of  an  attack  of  measles.  A.  K.  Bond 
(Maryland  Med.  Jour.,  Jan.  29,  '98). 

Endocarditis  and  pericarditis  are  seen 
in  rare  cases. 

Meningitis  may  occur  as  a  further 
complication,  through  the  presence  of 
otitis. 

Case  of  spinal  meningitis  complicating 
measles,  followed  by-  recovery.  The 
cranial  nerves  and  brain  were  unaffected. 
Starck  (Jahrb.  f.  Kinderh.  u.  phys. 
Erzieh.,  vol.  xlvii). 

Cellulitis  and  suppurative  adenitis  are 
uncommon,  but  moderate  enlargement  of 
the  cervical  glands  often  occurs  and 
sometimes  persists  for  months. 

The  occurrence  of  measles  simultane- 
ously with  other  infectious  diseases  is  not 
very  infrequent.  There  seems  to  be  a 
particular  tendency  to  the  simultaneous 
occurrence  of  measles  and  pertussis. 

Pertussis  as  a  complication  of  measles 
noted  21  times  in  166  cases.  E.  P.  Ber- 
nardy  (Annals  of  Gyn.  and  Ped.,  July, 
'94). 

Case  of  concurrent  measles  and  scarlet 
fever.  The  germs  of  the  measles  must 
have  been  in  the  system  of  the  child  at 
the  time  that  it  developed  scarlatina. 
C.  H.  Phillips  (Brit.  Med.  Jour.,  Dec.  20. 
'90). 

Case  of  measles  and  scarlatina  co- 
existent in  the  same  child  at  the  same 
time.  A.  A.  Himowich  (Med.  Eec,  Sept. 
7,  '95). 

Case  in  which  measles  co-existed  with 
chicken-pox.  F.  W.  Joshua  (Lancet. 
July  13,  '89). 

Case  of  concurrent  enteric  fever  and 
measles.  Juhel-Renoy  (Le  Bull.  M6d., 
Mar.  12,  '93). 

Case  in  which  typhus  and  measles  oc- 
curred in  a  patient  at  the  same  time. 
J.  Tenner  (Amor.  Medico-Surg.  Bull.. 
Aug.  15,  '94). 

Two  cases  of  urticaria  seen  during  the 
incubative  stage  of  measles.   Of  270  cases 


MEASLES.    COMPLICATIONS  AND  SEQUELAE. 


539 


of  measles,  croup  was  present  in  17  cases, 
and  in  3  cases  diphtheria.  Claus  (Jahrb. 
f.  Kinderh.  u.  phys.  Erzieh.,  June  5,  '94). 

Case  in  which  erysipelas  co-existed 
with  measles.  Measles  exerted  arresting 
influence  upon  erysipelas,  which,  in  turn, 
was  also  favorably  influenced  by  morbid 
process.  Janovski  (Med.  Obozrenije,  vol. 
xliv,  No.  15,  '95). 

Tuberculosis  is  the  most  serious  sequel 
of  measles.  It  commonly  occurs  as  a 
tubercular  broncho-pneumonia,  general 
miliary  tuberculosis,  tubercular  aden- 
itis, or  tubercular  joint  disease.  These 
conditions  may  result  from  primary  in- 
fection or  from  the  lighting  up  of  some 
old  tubercular  process.  Measles  unques- 
tionably renders  the  tissues  very  suscep- 
tible to  tubercular  bacilli;  so  that  infec- 
tion may  result  from  slight  exposure. 
Acute  miliary  tuberculosis  may  follow 
measles  at  once,  the  temperature-range 
being  continuous  from  the  outset  of  the 
primary  disease  to  death  from  the  com- 
plication. General  tuberculosis  with 
grave  pulmonary  involvement  may  fol- 
low so  close  upon  measles  as  to  leave  no 
appreciable  interval  between.  It  is  some- 
times the  cause  of  a  secondary  fever, 
which  develops  soon  after  the  subsidence 
of  the  primary  fever.  Tubercular  dis- 
ease of  the  bones  and  joints  subsequent 
to  measles  is  usually  of  late  occurrence. 

Case  of  disseminated  cutaneous  tuber- 
culosis consecutive  to  measles.  Du  Cas- 
tel  (Bull,  de  la  Soc.  Fran,  de  Derm,  et  de 
Syph.,  vi,  p.  86,  '95). 

Literature  of  '96-'97-'98. 

Tuberculosis  follows  measles  with  re- 
markable frequency.  J.  A.  Larrabee 
(Pediatrics,  Oct.  1,  '97). 

Chronic  conjunctivitis  is  a  frequent  se- 
quel of  measles  which  may  be  in  large 
degree  prevented  by  judicious  care. 
Iritis  and  keratitis  are  possible  sequels, 
but  are  not  common. 


Literature  of  '96-'97-'98. 

Case  of  bilateral  ophthalmoplegia  and 
right  hemiplegia  following  measles.  Ray- 
mond (Gaz.  Heb.  de  Med.  et  Chir.,  Jan. 
5,  '96). 

Prognosis. — Death  from  measles  in 
private  practice  is  rare  in  children  over 
four  years  of  age.  Holt,  after  the  study 
of  a  large  number  of  cases,  concludes  that 
the  mortality  of  the  disease  is  from  4  to 
6  per  cent.,  but  under  two  years  it  is 
often  20  per  cent,  or  more.  It  is  highest 
between  one  and  two  years,  but  even  at 
this  age  uncomplicated  measles  is  not  a 
highly-fatal  disease.  Pneumonia  is  the 
cause  of  death  in  almost  90  per  cent,  of 
fatal  cases. 

A  violent  onset  with  high  temperature 
warrants  a  guarded  prognosis.  A  rising 
temperature  with  a  fading  eruption  war- 
rants an  unfavorable  prognosis.  The 
I  same  is  true  when  the  eruption  is  excess- 
ive in  amount  and  confluent  over  wide 
areas.  Grave  general  symptoms  with 
faint  eruption  is  a  serious  condition. 
The  same  is  true  of  an  hemorrhagic  or 
black  eruption,  but  it  is  not  as  necessarily 
fatal  as  is  commonly  supposed. 

Literature  of  '96-'97-'98. 

The  mortality  from  measles  at  the 
Hopital  Trousseau  in  1895  was  14.4  per 
cent.;  715  children  were  admitted. 
Comby  (Lancet,  Mar.  21,  '96). 

The  death-rate  from  measles  during 
the  last  twenty  years  shows  that  there 
are  two  maxima,  one  in  December  and  a 
higher  one  in  May  and  June.  The  death- 
rate  has  diminished  during  the  last  ten 
years.  The  highest  mortality  is  found 
among  infants  during  the  first  year.  A 
rickety  chest  with  the  accompanying 
broncho-pneumonia  doubles  the  mor- 
tality. Moller  (Archiv  f.  Kinderh.,  vol. 
xxi,  '97). 

Measles  has  a  marked  tendency  to 
leave  behind  it  results  of  a  serious  nature. 
I  Treatment  should  not  be  directed  solely 


540 


MEASLES. 


PROPHYLAXIS. 


TREATMENT. 


to  saving  the  life  of  the  child  nor  should 
the  prognosis  be  made  up  solely  with 
reference  to  that  event.  The  tendency 
to  tubercular  invasion  should  never  be 
forgotten,  and  when  the  fever  persists 
after  the  tenth  day,  even  if  it  is  not  high, 
the  prognosis  should  be  guarded.  The 
list  of  chronic  affections  left  in  the  wake 
of  measles  is  a  long  one;  bronchitis, 
pharyngitis,  rhinitis,  adenoid  growths, 
enlarged  tonsils,  and  mesenteric  glands 
are  among  the  number  which  should  re- 
ceive consideration. 

Prophylaxis.  —  The  advisability  of 
taking  particular  precautions  against  the 
exposure  of  infants  is  suggested  by  the 
high  mortality  of  measles  before  three 
years.  Delicate  children  of  the  so-called 
scrofulous  type  and  those  with  heredi- 
tary tendency  to  tuberculosis  should  be 
especially  guarded  against  exposure. 
Early  and  absolute  isolation  of  the  sick  i 
is  imperative.  Quarantine  of  the  patient  | 
should  not  be  less  than  twenty-eight  days 
and  as  much  longer  as  purulent  dis- 
charges ma}^  continue.  The  period  of 
quarantine  after  exposure  should  not  be 
less  than  fifteen  days  and  twenty  days  is 
preferable.  Children  who  have  been  ex- 
posed should  be  isolated  from  other  chil- 
dren for  that  period. 

The  sick-room  is  less  liable  to  prove 
dangerous  than  is  the  scarlet-fever  sick- 
room. Thorough  cleansing  and  ventila-  I 
tion  for  two  weeks  after  the  patient  has 
left  it  is  sufficient  to  insure  safety.  The 
infection  of  measles  is  not  persistent  nor 
is  intermediate  infection  common;  so 
that  prolonged  precautions  are  not  neces- 
sary. During  the  height  of  the  disease 
the  same  measures  should  be  taken  to 
avoid  the  exposure  of  others  as  in  other 
infectious  diseases. 

Excellent  influence  of  the  closure  of 
schools  in  an  epidemic  of  measles: 
schools  were  closed  for  a  period  of  four 


weeks,  and  only  4  cases  appeared 
among  20,000  scholars  after  the  schools 
were  reopened.  Wolford  (Sanitary 
Record,  May,  '89). 

As  a  prophylactic  measure,  the  disin- 
fection of  the  nasal  fossa?,  the  mouth, 
pharynx,  genitals  and  anus  advised.  J. 
Comby  (La  Med.  Mod.,  Jan.  0,  '94). 

Literature  of  '96-'97-'98. 

In  order  to  avoid  the  broncho-pul- 
monary complications  of  measles  it  is 
necessary  to  realize  as  much  as  possible 
the  asepsis  of  rubeolous  patients  and  to 
disinfect  the  quarters  in  which  such  pa- 
tients are  cared  for.  Hutinel  (Med.  In- 
fant., July  1,  '97). 

Treatment. — The  patient  should  be 
placed  in  as  large  and  well  ventilated 
room  as  possible.  The  temperature 
should  not  be  kept  at  too  high  a  point 
nor  should  the  child  be  forced  to  swelter 
under  too  heavy  covering.  It  accom- 
plishes no  good  and  renders  the  child 
restless  and  irritable.  The  room  should 
be  kept  very  dark  and  no  direct  light 
should  be  permitted  to  fall  upon  the  eyes. 
As  the  inflammation  of  the  eyes  subsides, 
the  light  should  be  gradually  admitted, 
but  full  light  should  not  be  permitted 
until  the  conjunctiva?  have  become  nor- 
mal in  appearance.  Itching  of  the  lids 
should  be  relieved  by  cold  cloths  or  by 
the  application  of  cold  cream  or  some 
bland  oil.  If  a  purulent  discharge  ap- 
pears the  eyes  should  be  kept  clean  by  a 
frequent  application  of  a  solution  of 
boric  acid. 

"When  troublesome  pulmonary  symp- 
toms are  present  and  severe  inflammation 
of  the  eyes,  fluid  extract  of  eucalyptus, 
in  5-drop  doses.  For  eyes,  solution  of 
mercuric  chloride  (1  to  12.000).  a  drop  or 
two  instilled  twice  daily  and  followed  by 
washing  with  solution  of  borax  in  warm 
water.  Wells  (Phila.  Polyclinic.  .Inly  13; 
'95). 

The  child  should  be  put  to  bed,  even 
in  the  mildest  cases,  and  kept  there  until 


MEASLES.  TREATMENT. 


541 


desquamation  is  practically  completed. 
The  diet  should  consist  of  milk  and  broth 
during  the  febrile  stage;  during  the 
height  of  the  disease  the  child  should  not 
be  overurged  to  eat. 

Applications  of  plain  or  carbolized 
vaselin  do  much  to  reduce  the  irritability 
of  the  skin.  As  soon  as  the  eruption  be- 
gins to  subside,  inunctions  of  plain  or 
carbolized  vaselin  or  ichthyol  ointment 
should  be  practiced  daily.  A  daily  warm 
bath  does  much  to  hasten  desquamation. 

Literature  of  '96-'97-'98. 

Over  three  hundred  personally  treated, 
with  a  mortality  of  only  four.  This 
low  rate  of  mortality  attributed  to  the 
method  of  treatment  invariably  adopted, 
namely:  jacket  poultices,  to  be  changed 
as  soon  as  any  indications  of  measles 
show  themselves  and  before  the  rash 
appears.  The  only  medicinal  treat- 
ment adopted  has  been  ipecacuanha- 
wine  with  acetate  of  ammonia,  with  a 
boric-acid  wash  for  the  eyes  in  those 
cases  which  were  complicated  by  catar- 
rhal inflammation  of  the  lids.  Stoma- 
titis occurred  in  about  one-half  of  the 
cases  and  invariably  yielded  to  the  ap- 
plication of  a  saturated  solution  of 
chlorate  of  potash.  A.  Dunley  Owen 
(Lancet,  June  20,  '97). 

If  ichthyol  salve  can  be  applied  in 
measles  from  the  very  first,  it  aborts  the 
infection.  If  the  eruption  is  already  ap- 
parent, with  hyperthermia  and  bron- 
chitis, the  temperature  returns  to  normal 
after  one  or  two  rubbings,  and  the 
patches  grow  pale  and  disappear.  In 
four  or  five  days  the  cure  is  complete, 
when  a  warm  bath  is  given  to  remove 
the  traces  of  the  salve.  The  salve  is 
rubbed  in  all  over  the  body,  morning  and 
night:  7  l/2  drachms  of  ichthyol  to  3 
ounces  of  lard.  A.  Strizovere  (Jour. 
Amor.  Med.  Assoc.,  Apr.  30,  '98). 

The  hard  metallic  cough  is  one  of  the 
most  troublesome  symptoms  of  the  dis- 
ease. Very  little  relief,  however,  can  be 
afforded  by  treatment  before  the  fever 
begins  to  subside.   Tt  cannot  be  loosened 


by  the  administration  of  nauseating  ex- 
pectorants. They  tend  to  render  the 
child  more  irritable  and  to  increase  the 
anorexia  and  have  but  slight  effect  on  the 
cough.  Small  doses  of  opium  aid  in 
allaying  the  cough,  and  are  quite  per- 
missible. Brown  mixture  in  the  form  of 
tablet  triturates  is  as  effective  as  any 
treatment  and  is  easy  of  administration. 

Cool  water  and  ice-pellets  give  some 
relief  in  the  cough  of  measles.  A  mixt- 
ure of  bromides,  chloral,  and  deodorized 
tincture  of  opium  in  a  syrupy  vehicle 
gives  good  results.  Tyler  (Amer.  Jour, 
of  Obstet.,  Aug.,  '88). 

Though  hyperpyrexia  is  uncommon  in 
measles,  the  fever  sometimes  requires 
attention.  The  effect  of  the  fever  upon 
the  patient  is  a  better  guide  for  treat- 
ment than  is  the  thermometer.  If  the 
child  becomes  restless  or  delirious,  small 
doses  of  phenacetin  are  admissible.  Only 
enough  should  be  given  to  reduce  the 
temperature  moderately  and  to  allay  rest- 
lessness. Cold  sponging  is  the  best  treat- 
I  ment  for  high  temperature  and  is  far 
preferable  to  the  administration  of  large 
doses  of  antipyretics. 

Use  of  cold  baths  in  ataxo-adynamic 
forms  of  measles  followed  by  marvelous 
results.  Juhel-Renoy  and  Duponchel  (La 
Tribune  Med.,  May  15,  '90). 

Case  of  measles,  rapidly  assuming  the 
malignant  form,  apparently  cured  by 
cold  baths,  but  improvement,  did  not 
appear  until  after  the  fourth  bath.  As 
a  consequence  of  the  cold  baths,  the  sup- 
pressed function  of  the  kidneys  was  re- 
sumed. Dieulafoy  (La  Med.  Mod.,  June 
20.  '90). 

Thirty-six  cases  of  measles  in  children 
successfully  treated  in  the  following 
manner:  The  entire  body  of  the  child 
was  immersed  in  cold  water,  rubbed  with 
a  moist  sponge,  and  the  trunk  covered 
with  a  cloth  wrung  dry  out  of  cold 
water.  The  ablutions  should  be  made 
every  hour  if  the  temperature  rises  above 
102.2°  F.,  but  only  once  at  night.  Even 
after  disappearance  of  the  fever  cold  or 


542 


MEASLES.  TREATMENT. 


warm  baths  should  be  given.  J.  Fodor 
(Blatter  f.  klin.  Hydrotherapie,  etc., 
July,  -91). 

In  the  eruptive  fevers  hydrotherapy 
affords  better  means  of  controlling  the 
pyrexia  and  the  accompanying  nervous 
phenomena  than  treatment  by  anti- 
pyretic remedies.  Pulmonary  congestion 
and  broncho-pneumonia  are  also  favor- 
ably influenced  by  baths,  the  water  be- 
ing gradually  cooled,  while  cold  water 
is  poured  on  the  head.  Guinon  (Blatter 
f.  klin.  Hydrotherapie,  etc.,  July,  '91). 

Life  was  prolonged  in  two  or  three 
cases  of  measles  by  means  of  gavage,  or 
forced  feeding.  In  cases  with  cyanosis, 
high  temperature,  and  great  dyspnoea, 
hot  mustard  baths,  and  mustard  to  the 
entire  body  seemed  to  be  more  service- 
able than  any  other  means  used.  L. 
Emmett  Holt  (Brit.  Med.  Jour.,  Mar.  18, 
'93). 

Literature  of  '96-'97-'98. 

Antipyrine  valuable  as  an  antithermic 
in  measles.  This  drug  is  given  to  pa- 
tients when  their  temperature  reaches 
or  exceeds  103°,  the  following  formula 
being  employed:  — 

R  Syrup,  3.8  ounces. 

Antipyrine,  75  grains. 
Editorial  (N.  Y.  Med.  Jour.,  Feb.  8,  ' 
'96). 

As  a  rule,  hydrotherapy  is  unnecessary 
in  measles,  but  should  the  following  con- 
ditions arise  it  is  useful:  Should  the 
patient  be  stuporous,  or  if  there  be 
marked  delirium  and  convulsions,  cold 
affusions  at  60°  to  70°,  lasting  for  two 
minutes,  may  be  applied  to  the  head  and 
neck.  If  this  is  insufficient  to  reduce 
the  temperature,  then  a  bath  of  70°  to 
80°,  lasting  for  five  minutes,  with  colder 
affusions  to  the  head,  may  be  used. 
Should  there  be  signs  of  laryngeal  steno- 
sis, it  may  be  well  to  place  the  child  in 
a  hot  bath  or  in  a  hot  pack  for  from 
fifteen  to  twenty  minutes.  Should  the 
face  become  very  much  congested,  cold 
affusions  may  be  applied  to  the  head  or 
an  ice-bag  may  be  used.  Should  the 
temperature  become  subnormal,  a  hot 
bath  may  be  given  accompanied  by  ener- 
getic rubbing.  Where  there  are  evidences 


of  catarrhal  bronchitis  it  may  be  well  to 
apply  sudden  cold  affusions  to  the  chest 
and  to  follow  these  immediately  after- 
ward by  the  administration  of  an  emetic. 
Jurgensen  (Blatter  f.  klin.  Hydrothera- 
pie; Therap.  Gaz.,  July  15,  '98). 

Uncomplicated  cases  do  not  require 
stimulants.  Broncho  -  pneumonia  re- 
quires the  same  treatment  that  it  would 
receive  under  other  conditions.  Other 
complications  must  be  treated  as  they 
arise. 

Medicinal  treatment  not  considered 
necessary  in  cases  which  run  the  regular 
course.  Alimentation  is  the  treatment 
for  high  temperature.  Suggestion  of 
Semmola  and  Dujardin-Beaumetz  to  sub- 
stitute glycerin  for  alcohol  is  a  very 
good  one.  An  ounce  of  glycerin  may  be 
given  daily,  combined  with  about  8 
ounces  of  water  and  1/2  drachm  of  citric 
or  tartaric  acid. 

Treat  broncho-pulmonary  complica- 
tions with  a  combination  of  infusion  of 
ipecacuanha,  tincture  of  aconite,  and 
syrup.  When  the  cough  is  particularly 
rebellious,  good  results  are  obtained  by 
giving  iodide  in  combination  with  bro- 
mide of  sodium.  Montefusco  (Revue 
Mens,  des  Mai.  de  l'Enfance,  Aug.,  '88). 

Use  of  potassium  iodide  in  daily 
amounts  of  3  to  12  grains  advised,  in  the 
broncho-pneumonia  of  measles.  Bicente 
(X.  Y.  Med.  Jour.,  Apr.  21,  '94). 

Epidemic  of  measles  in  a  young  girls' 
seminary,  with  10  per  cent,  of  acute  lobar 
pneumonia.  Digitalis  in  large  doses.  No 
depressing  effect  upon  the  heart.  Lomi- 
kovsky  (La  Med.  Mod.,  Feb.  27,  '95). 

Successful  stamping  out  of  broncho- 
pneumonia, occurring  as  a  complication 
in  a  hospital.  Child  given  sublimate 
baths;  every  sore,  abscess,  or  crust  of 
impetigo  carefully  dressed;  nose  and 
fauces  irrigated  several  times  daily  with 
boric  solution  or  boiled  water;  every 
child  affected  with  broncho-pneumonia 
promptly  isolated.  Hutinel  (La  Med. 
Mod.,  Jan.  20.  '95). 

Following  treatment  employed  in  the 
paralysis  following  measles:  Should 
paralysis  depend  upon  simple  congestion 
of  the  marrow  it  is  to  be  treated  with 
ergot,  strychnia,  and  the  galvanic  cur- 


MEASLES. 


MEDIASTINUM.  ABSCESS. 


543 


rent  to  the  spine,  followed  by  a  cold  I 
douche,  the  faradic  current  being  em- 
ployed at  the  same  time.  This  should  j 
be  followed  by  dry  friction,  sulphur-  and 
sea-  baths.  If  the  symptoms  do  not  sub- 
side, iodide  of  potassium  should  be  given 
in  small  doses.  Heat  may  be  applied  to 
the  spine  or  an  eschar  made  with  the 
thermocautery.  Calomel  in  small  doses 
is  of  service.  Should  respiration  be- 
come difficult  or  the  heart  fail,  artificial 
respiration  and  injections  of  ether  must 
be  used.  If  congestion  is  evident,  a  wet 
cup  should  be  applied  to  the  nape  of  the 
neck.  In  case  of  retention  of  urine  a 
catheter  must  be  passed  two  or  three 
times  a  day.  Bayle  (Revue  de  Ther. 
Medico-Chir.,  Mar.  1,  '88). 

Literature  of  '96-'97-'98. 

The  treatment  of  measles  should  be 
directed  to  the  prompt  development  of 
the  eruption.  For  this  purpose  the  io- 
dides with  diaphoretics  are  valuable.  In 
cases  of  retarded  eruption,  the  sheet  pack 
wrung  out  of  hot  water  in  which  a  table- 
spoonful  of  mustard-flour  has  been 
steeped  has  proved  effectual.  The 
bowels,  if  constipated,  should  be  relieved 
by  enemata.  The  apartment  in  which 
the  patient  remains  should  be  airy  and 
well  ventilated,  without  draughts,  and 
with  facilities  for  maintaining  a  moder- 
ate amount  of  darkness,  and  an  equable 
temperature,  night  and  day,  of  70°  F. 

To  develop  the  eruption  and  allay  in- 
cessant laryngeal  cough  the  following 
may  be  given:  — 

I£  Syrup  of  hydriodic  acid, 
Syrup  of  Dover, 

Syrup  of  Tolu,  of  each,  1  ounce. 
The  Dover  syrup  to  be  lessened  for  in- 
fants. 

During  the  eruptive  stage  and  through- 
out a  broncho-pneumonia  give:  — 

R.  Potassium  acetate,  2  drachms. 
Solution  of  ammonium  acetate, 
Camphor-water,  of  each,  3  ounces. 

A  teaspoonful  to  be  given  every  hour 
to  a  child,  and  a  tablespoonful  every 
hour  to  an  adult.  This  treatment  should 
be  accompanied  by  the  use  of  copious 
draughts  of  water.  J.  A.  Larrabee  (Pedi- 
atrics, Oct.  1,  '97). 


Cocaine  has  proved  a  sovereign  remedy 
in  bringing  out  the  eruption  in  a  few 
hours  in  three  cases  of  abnormal  measles. 
Generally  it  was  administered  in  a  daily 
amount  of  0.3  grain  to  children  five 
years  old.  M.  Poulet  (N.  Y.  Med.  Jour., 
June  5,  '97). 

Phlyctenular  conjunctivitis  with  its 
array  of  dangerous  complications,  includ- 
ing ulceration  of  the  cornea,  is  often  wit- 
nessed in  dispensaries  as  a  sequel  of 
measles.  This  is  mainly  due  to  the  fact 
j  that  text-books  on  diseases  of  children 
do  not  lay  sufficient  stress  upon  the  im- 
portance of  keeping  the  lids  aseptic  by 
careful  cleansing,  and  not  using  the  eyes 
for  reading,  writing,  etc.,  until  the  sys- 
tem has  completely  recovered  from  the 
debilitating  influence  of  the  disease,  in 
which  the  ocular  muscles  take  an  active 
part. 

During  convalescence,  unusual  care 
should  be  exercised  in  avoiding  unneces- 
sary exposure.  Tonics  should  be  given 
freely.  The  various  sequela?  should  re- 
ceive proper  attention,  and  the  particular 
susceptibility  to  tuberculosis  should  not 
.  be  forgotten. 

Floyd  M.  Crandall, 

New  York. 

MEDIASTINUM,  DISORDERS  OF 
THE. 

Mediastinal  Abscess. 
Symptoms. — In  an  analysis  of  over  one 
hundred  cases  Hare  found  that  the  most 
constant  and  severe  symptom  of  medi- 
astinal abscess  was  pain,  unless  the 
formation  was  cold  abscess,  when  the 
pain  was  a  very  unimportant  factor.  In 
both  the  acute  and  chronic  form  flashes 
of  heat  and  rigors  may  occur,  particu- 
larly the  latter  in  the  acute  forms. 

Pulsation  may  be  perceptible  by  palpa- 
tion and  by  the  sensation  of  the  patient 
from  the  pressure  on  large  blood-vessels, 
and  the  sense  of  pulsation  is  intensified 


MEDIASTINUM.    ABSCESS.  ETIOLOGY. 


by  the  outside  pressure  upon  the  accu- 
mulation. Abscess  of  the  posterior  spaces 
may,  by  its  pressure  on  the  nerves  as 
they  leave  the  cord,  produce  violent  pain 
in  the  anterior  wall  of  the  chest.  Dys- 
phagia is  not  so  marked  as  in  other 
growths  of  the  chest.  There  is  a  sensa- 
tion of  weight  under  the  sternum,  the 
tissues  overlying  the  latter  being  fre- 
quently cedematous.  Dyspnoea  is  occa- 
sionally complained  of.  General  symp- 
toms— fever,  anorexia,  etc. — are  usually 
present,  and  become  quite  marked  when 
the  accumulation  of  pus  is  marked. 

Case  of  abscess  of  posterior  medias- 
tinum, with  cyanosis  and  subcutaneous 
emphysema;  venesection;  recovery  by 
discharge  through  the  lung. 

A  remarkable  feature  was  a  high  de- 
gree of  subcutaneous  emphysema,  which 
extended  over  the  neck  and  the  upper 
part  of  the  chest.  William  Pepper  (Inter. 
Med.  Mag.,  Feb.,  '92). 

Case  of  mediastinal  abscess  in  a  soldier 
upon  whom  a  heavily-laden  sack  had  fal- 
len while  he  was  lying  down.  Some  days 
afterward  he  experienced  severe  pain  in 
respiration  and  gradually  became  weak 
and  emaciated.  Some  eight  months  later 
he  noticed  a  tumor  the  size  of  a  hazel-nut 
on  the  right  edge  of  the  sternum  above 
the  second  rib.  This  grew  rapidly,  and 
in  a  month  he  could  only  breathe  when 
lying  down,  the  sense  of  pressure  being 
very  great.  An  incision  over  the  tumor 
brought  12  3/4  ounces  of  pus  from  above 
the  sternum.  The  size  of  the  incision  was 
increased.  Abundant  irrigation  and 
cauterization  with  zinc  chloride  at  10  per 
cent,  were  then  employed,  with  tampons 
of  iodoform  gauze,  but  no  sutures.  Re- 
covery was  uneventful.  Hassler  (La 
Sem.  Med.,  Oct.  10.  '04). 

Diagnosis. — -The  pressure  on  the  im- 
portant nerves  involved  the  pneumogas- 
tric,  the  recurrent  laryngeal,  etc.,  and 
the  vascular  trunks  sometimes  markedly  j 
simulate  aneurism.  The  difficulty  in 
breathing  and  the  brassy  sound  of  voice 
recall  the  symptoms  of  thoracic  aneu-  I 


risms.  But  the  violent  pain  at  times  ex- 
perienced by  aneurisms  is  usually  absent, 
though  there  may  be  marked  discomfort. 

An  exact  diagnosis  in  suppuration  of 
the  mediastinum  is  important,  owing  to 
the  probability  of  rupture  of  an  abscess 
into  the  serous  cavities,  terminating  in 
pleuritis,  peritonitis,  pericarditis,  or  later 
septicaemia. 

Case  of  abscess  of  the  mediastinum, 
consecutive  to  tracheotomy,  with  sudden 
death.  The  patient  was  a  child  with 
croup.  A  sac  of  pus  enveloped  the  pneu- 
mogastric  nerve.  Fromaget  (Jour,  de 
Med.  de  Bordeaux,  Feb.  15,  '01). 

Etiology. — Mediastinal  abscesses  may 
be  idiopathic,  secondary,  or  traumatic. 
The  idiopathic  form  is  quite  rare;  the 
secondary  form  may  result  from  lesions 
in  neighboring  parts,  —  the  neck  or 
thorax,  —  while  the  traumatic  follows 
blows,  contusions,  penetrating  wounds, 
and  fracture  of  the  overlying  bones. 
Abscess  of  the  mediastinum  affects  males 
more  frequently  than  females.  In  Hare's 
cases  the  proportion  was  as  58  is  to  10. 
The  anterior  mediastinum  is  the  most 
common  seat  for  its  development  (in  the 
proportion  of  48  to  19  instances  of  the 
disease  in  all  the  other  spaces).  The  pro- 
portion of  acute  to  cold  abscess  was  also 
noted  by  Hare  to  be  as  40  is  to  31  in  111 
cases  examined.  Mediastinal  abscess  is 
nearly  as  frequent  as  cancer;  it  occurred 
in  136  cases  of  the  520  growths  collected. 
Abscess  is  more  frequent  than  sarcoma, 
of  which  only  90  occurred,  of  the  last 
number  mentioned. 

Mediastinal  abscess  is  occasionally  a 
symptom  of  Pott's  disease,  especially  if 
the  two  lower  cervical  vertebrae  are  in- 
volved. Tt  also  occurs  as  a  complica- 
tion after  tracheotomy  or  oesophagotomy. 
The  most  frequent  cause,  however,  seems 
to  be  pericarditis. 

Pathology. — Mediastinal  abscesses  arc 
attended  usually  with  obstruction,  to  a 


MEDIASTINUM.    MEDIASTINO-CARDIAC  DISORDERS. 


545 


greater  or  less  extent,  of  air-  and  blood- 
channels  from  the  pressure  upon  them, 
and  are  recognized  by  dullness  on  per- 
cussion over  the  region  involved.  An 
opening  may  exist,  or  bulging  of  the 
ribs  with  pulsation  may  occur,  but  such 
an  accumulation  in  the  mediastinal 
spaces  may  not  reach  the  exterior  sur- 
face, owing  to  the  sternum  in  front  and 
the  spinal  column  with  the  heavy  mus- 
cles behind,  while  abscess  of  the  middle 
mediastinum  must  involve  the  lungs  or 
the  lateral  spaces  before  coming  into 
notice. 

Treatment. — The  only  safe  course  in 
such  cases  is  to  trephine  the  sternum  and 
to  carefully  explore  the  mediastinum, 
ascertaining  with  an  exploratory  needle 
whether  pus  is  present.  This  is  usually 
ascertained  without  trouble.  The  cavity 
should  then  be  opened,  gently  washed 
out,  and  drained. 

The  advantage  accruing  from  drain- 
age in  other  parts  is  greater  in  medias- 
tinal abscesses,  and  early  incision,  or  re- 
section of  a  rib  or  portion  of  the  sternum, 
is  not  only  indicated,  but  demanded. 
The  urgent  symptoms  calling  for  this 
course  may  be  mentioned: — 

1.  Dysphagia,  or  pressure  upon  the 
oesophagus. 

2.  Enlargement  to  the  left  of  the 
sternum,  and  at  times  to  the  right. 

3.  Displacement  of  important  organs, 
sueli  as  the  heart  or  lungs. 

I.  Dullness  and  flatness  of  the  region 
of  the  lungs. 

5.  Thorough  drainage  may  be  made 
also  when  the  cause  of  trouble  is  a  cyst 
or  a  serous  collection;  so  that  no  special 
difference  need  be  made. 

Case  of  dermoid  cyst  of  the  anterior 
mediastinum  in  a  soldier  22  years  of  age. 
The  whole  righl  chest  was  enlarged. 
After  three  weeks  of  expectant  treatment 
25  ounces  of  yellowish  liquid  were  with- 
drawn by  aspiration.    The  fluid  was  not 

4- 


purulent.  Improvement  follow  ed  at  once. 
A.  Dardignac  (Revue  de  Chir.,  Sept..  '94). 

6.  Chills  or  hectic  indicate  pyaemia, 
and  call  for  s}'stemic  as  well  as  local 
treatment. 

Mediastino-Cardiac  Disorders  and  In- 
juries. 

The  heart  is  intimately  associated  with 
almost  all  of  the  contents  of  the  whole 
mediastinum,  but  especially  the  large 
veins  and  arteries,  which  commence  or 
terminate,  as  the  case  may  be,  within 
the  pericardium. 

Mediastino-pericarditis  is  a  fre- 
quent complication  of  mediastinal  in- 
flammation and  usually  terminates  in 
serous  effusion  before  it  is  fully  recog- 
nized. At  times  the  serous  effusion  is 
absorbed,  as  is  the  case  in  pleural  ef- 
fusions of  a  serous  nature.  The  afebrile 
type  of  pericarditis  may  be  fatal,  how- 
.  ever,  and  no  effusion  exist.  The  most 
serious  result  is  suppurative  pericarditis. 

Treatment. — Aspiration  and  drainage 
are  indicated  in  serous  pericardial  ef- 
fusions. Incision  and  drainage  should 
be  performed  for  the  relief  of  suppura- 
tive pericarditis.  The  site  for  either  of 
these  operations  is  that  between  the 
fourth  and  fifth  ribs, — about  one  inch  to 
the  right  or  left  of  the  sternum. 

Literature  of  '96-'97-'98. 

Operation  is  indicated  in  all  cases  of 
purulent  pericarditis.  The  operator 
should  avoid  opening  the  pleural  cavity, 
open  the  pericardium  opposite  the  point 
where  drainage  would  remain  good  after 
contraction  of  the  sac,  and  secure  perma- 
nent free  drainage.  C.  B.  Porter  (Med, 
News,  May  S,  '07). 

Pericardia]  effusions  should  be  treated 
in  the  same  manner  as  pleural  effusions, 
paracentesis  being  insufficient  to  cure 
suppurative  pericarditis.  Incision  and 
drainage  are  essential,  and  should  be 
executed  as  soon  as  the  diagnosis  of  pus 
in  the  pericardium  is  made.    The  diagno- 

35 


54G 


MEDIASTINUM.    VASCULAR  DISORDERS  AND  INJURIES. 


sis  of  the  purulent  character  of  the  effu- 
sion is  determinable  only  by  exploratory 
puncture.  This  should  be  done  at  the 
upper  part  of  the  left  xiphoid  fossa,  close 
to  the  top  of  the  angle  between  the 
seventh  cartilage  and  the  xiphoid  car- 
tilage. Pericardiotomy  should  then  be 
done  after  resection  of  the  fourth  and 
fifth  costal  cartilages,  raising  a  trap-door 
of  these  cartilages  and  using  the  tissues 
of  the  third  interspace  as  a  hinge.  The 
mammary  vessels  and  pleura  are  thus  ex- 
posed and  pushed  to  the  left.  The  prog- 
nosis is  good  after  pericardiotomy  for 
pyopericardium.  Of  26  collected  cases 
there  were  10  recoveries  and  16  deaths. 
Of  the  fatal  cases,  9  were  septic,  and  all 
the  others  which  died  had  complicating 
lesions, — pulmonary,  cardiac,  or  renal. 
J.  B.  Roberts  (Med.  News,  May  8,  '97). 

Injuries. — Wounds  of  the  heart  and 
pericardium  may  now  be  classed  as  other 
injuries  of  a  similar  kind,  since  Eehn 
has  successfully  sutured  penetrating- 
wounds  of  the  heart  with  catgut.  Eehn 
recommends  free  opening  in  cases  of 
hemothorax,  and  in  hasmopericardium 
this  is  necessary  to  prevent  the  formation 
of  bloody  froth.  (James  P.  Warbanes, 
Annals  of  Surgery,  Nov.,  '98). 

Among  the  rarer  injuries  to  the 
contents  of  the  mediastinum  that  may 
be  mentioned  is  rupture  of  the  heart, 
which  has  been  demonstrated  post-mor- 
tem. It  may  be  diagnosticated  by  the 
peculiar  pallor,  the  sudden  cessation  of 
the  rhythm  and  beat  of  the  heart,  to- 
gether with  the  total  irresponsive  con- 
dition of  the  circulation  to  all  stimu- 
lants. 

Mediastinal  Vascular  Disorders  and 
Injuries. 

Diseases. — The  diseases  of  the  blood- 
vessels of  the  mediastinum  are  those 
found  in  the  vascular  supply  of  other 
parts,  viz.:  aneurism,  phlebitis,  arteritis, 
etc.  (See  Aneurism  and  Vascular 
System.) 


Literature  of 

Case  of  aneurism  of  the  transverse  arch 
of  the  aorta  that  ruptured  into  the  medi- 
astinum and  dissected  along  the  muscles 
and  about  the  pharynx  and  larynx,  caus- 
ing death.  There  was,  marked  lividity 
and  swelling  of  the  face  and  neck  and 
some  dyspnoea.  J.  0.  Affleck  (Edinburgh 
Med.  Jour.,  June,  '98 ) . 

Treatment. — Inunctions  of  mercurial 
ointment,  iodine,  belladonna,  and  cam- 
phor ointments  may  be  made  externally, 
!  so  as  to  combat  inflammation.  Deple- 
tion by  calomel  and  soda,  or  by  vene- 
section, has  given  marked  relief. 

Wounds. — The  vascular  trunks  pass- 
ing through  the  mediastinum  are  so  dis- 
posed that  a  missile  which  penetrates  the 
cavity  may  traverse  it  without  wounding 
any  important  vein  or  artery.  The  aorta 
and  vena  cava,  when  wounded,  obviously 
do  not  admit  of  time  for  any  arrest  of 
the  haemorrhage.  The  most  prudent 
course  to  pursue  in  all  penetrating- 
wounds  is  to  hermetically  seal  the  outer 
wound,  after  turning  the  patient  upon 
the  side  affected,  so  that  all  blood  may 
be  allowed  to  escape.  This  course  has 
recently  stood  the  test  of  experience  in 
military  surgery,  and  Senn  counsels  it. 
in  preference  to  opening  the  wound  and 
ligating  any  bleeding  vessels.  In  case 
a  great  amount  of  blood  should  collect 
in  the  mediastinum,  it  may  be  evacuated 
posteriorly  by  resection  of  a  portion  of 
the  rib  near  the  point  of  the  greatest 
collection.  The  rise  of  temperature  no- 
ticed after  wounds  of  this  character  be- 
tokens more  the  absorption  of  fibrin 
than  actual  haemorrhage. 

]  In  the  senior  editor's  experience  a 
case  occurred  in  which  a  pistol-shot 
traversed  the  mediastinum,  the  ball  en- 
tering immediately  over  the  heart  and 
lodging  upon  the  sixth  rib  of  t ho  right 
side  behind  the  axillary  line.  The  ex- 
ternal wound  was  occluded,  and  the  ball 


MEDIASTINUM.    VASCULAR  DISORDERS  AND  INJURIES. 


547 


was  not  removed  until  after  the  general  | 
shock  and  slight  inflammatory  reaction 
had  passed  off.   The  patient  made  a  good 
recovery  by  the  strict  observance  of  mas- 
terly inactivity. 

This  case  - —  compared  to  another  in 
which  the  external  wound  was  left  open, 
terminating  fatally  —  emphasizes  the 
caution  against  cutting  down  and  ex- 
tracting a  ball  under  such  circumstances 
at  the  outset.  The  practice  of  removing 
balls  lodged  between  the  ribs  is  more 
honored  in  the  breach  than  in  the  ob- 
servance. When  an  opening  already  has 
been  made  by  the  entrance  of  a  ball,  it 
is  not  good  surgery  to  make  another  for 
the  extraction,  until  the  wall  behind  has 
become  solidified.  J.  McFaddex  Gas- 
ton, Sr.] 

Thoeacic  Duct.  —  This  may  be  the 
seat  of  disease  through  the  extension  of 
inflammation  in  the  various  forms  of  me- 
cliastinitis;  or  it  may  be  itself  in  a  nor- 
mal condition  and  be  the  recipient  of 
direct  or  indirect  pressure  sufficient  to 
rupture  its  walls  with  extravasation  of 
contents.  Again,  it  is  often  the  only 
part  involved  in  a  stab-wound  of  the 
mediastinum.  The  chyle  cannot  be  lost 
to  the  system  without  serious  results, 
and  most  wounds  of  the  thoracic  duct  are 
fatal.  At  times,  however,  spontaneous 
closure  of  the  wound  occurs,  when  the 
incision  is  a  longitudinal  one. 

[A  recent  case  of  recovery  reported  by 
H.  W.  Lyne,  of  Richmond,  Va.  (Virginia 
Med.  Semimonthly,  Aug.  26,  '97)  demon- 
strates the  possibility  of  so  desirable  an 
ending. 

The  thoracic  duct  was  ruptured,  and 
closed  spontaneously  in  the  case  of  a 
child  reported  by  Kirchner  (Arch.  f.  klin. 
Chir.,  '85,  p.  156).  The  displacements  of 
heart,  liver,  and  other  organs  was  very 
marked. 

The  treatment  in  this  case  consisted  in 
a  puncture  arid  evacuation  of  a  portion 
of  the  fluid,  followed  by  active  purgation. 
The  child  had  been  violently  thrown 
against  a  window-sill,  so  that  she  was  in- 
jured about  the  level  of  the  third  rib. 
The  puncture  revealed  the  fluid  extrava- 


sated  to  be  chyle.  Six  months  after  the 
accident,  the  girl  is  described  as  being  in 
better  health  than  before  it. 

The  wounds  of  all  kinds  have  been  few 
if  they  have  been  recorded.  W.  W. 
Keen,  of  Philadelphia,  has  had  one  case 
of  operation-wound  of  the  thoracic  duct. 
The  wound  Mas  sutured  very  carefully 
with  the  finest  semicircular  Hagedorn 
needle  and  fine  silk,  and  no  untoward 
result  occurred.  The  weight  of  the  pa- 
tient was  carefully  taken  for  some  days 
after  the  operation  and  no  great  decrease 
was  noticed.  Keen  records  three  other 
cases  of  wounds  in  the  cervical  portion  of 
the  thoracic  duct. 

These  cases  were  also  operation- 
wounds.  One,  that  of  Cheever  (Boston 
Med.  and  Surg.  Jour.,  75,  p.  422),  died 
from  exhaustion.  Another  case  was 
Boegehold's  (Arch.  f.  klin.  Chir.,  '93,  vol. 
xxix.  p.  443).  Wilms  was  the  operator, 
and  the  patient  recovered.  The  third 
case  was  in  an  operation  of  A.  M.  Phelps, 
of  Xew  York,  who  communicated  the 
facts  to  Keen  personally.  The  operation 
occurred  June  4,  and  on  June  11th  the 
wound  was  closed  by  haemostatic  forceps, 
and  the  patient  recovered,  beginning  to 
gain  in  weight  after  the  closure. 

Twenty  cases  of  wounds  of  all  kinds 
are  mentioned,  and  many  observations 
made  during  the  treatment  of  them, 
leading  to  the  inference  that  the  duct 
was  closed  spontaneously  in  some  of 
these  cases  and  a  collateral  anastomosis 
was  established;  but  the  continual  es- 
cape of  chyle  may  cause  death  by  the 
pressure  of  the  extravasated  fluid,  result- 
ing in  pleuritis,  or  that  death  may  be 
attributed  to  the  immediate  exhaustion, 
as  in  Cheever's  case. 

The  usual  size  of  the  thoracic  duct  is 
that  of  a  goose-quill,  and  the  jet  of  chyle 
will  be  of  low  pressure  and  about  the 
diameter  of  a  straw.  The  junction  of  the 
left  subclavian  vein  with  the  jugular 
vein  is  the  site  for  the  month  of  the 
duct  to  be  found,  but  anatomists  call 
attention  to  the  somewhat  frequent 
change  in  the  location,  due  to  the  fact 
that  the  duct  may  empty  its  contents 
into  the  left  subclavian  vein  by  several 
mouths,  comparable  to  the  delta  of  a 
river  (Med.  and  Surg.  Reporter,  May  12, 


548 


MEDIASTINUM.  TUMORS. 


'94).  J.  McTaddex  Gaston,  Sr.  and  I 
Jr.] 

Lymphatic  Glands. — The  lymphatic 
glands  of  the  mediastinum  are  divided 
by  Barety  into  three  sets:  (1)  the  right 
and  left  peribronchial;  (2)  the  right  and 
left  subbronchial;  and  (3)  interbron- 
chial.  All  these  are  particularly  liable  [ 
to  inflammatory  process. 

Three  cases  in  which  mediastinal 
glands  invaded  the  limgs,  all  in  children 
under  two  years  of  age.  Caseous  glands 
in  children  found  present  in  110  cases  out 
of  the  last  300  necropsies  made  at  the 
Children's  Hospital.  Their  occurrence 
apart  from  some  tuberculous  affection  i 
doubtful.  Voelcker  (Brit.  Med.  Jour., 
May  9,  '91). 

Inflammation  of  the  cellular  tissue 
may  be  acute  or  chronic,  primary  or  sec- 
ondary. Inflammatory  changes  may  be 
circumscribed  or  diffused.  The  condi- 
tion of  the  tissues  in  the  neighborhood 
is  to  be  taken  into  account  in  determin- 
ing the  inflammation.    (See  Adenitis.) 

Tumors  of  the  Mediastinum. 

Symptoms. — The  attachments  of  the 
tumor  and  the  encroachment  of  the  rapid 
growth  necessarily  have  important  bear- 
ings upon  the  symptoms  manifested. 
Tor.  instance,  in  multiple  sarcomata  of 
the  heart  the  heart-beat  is  rapid  and 
irregular,  but  there  may  bfe  no  murmurs 
unless  the  valves  are  encroached  upon. 
At  times,  instant  death  is  caused  by  the 
pressure  of  the  tumor  upon  the  spinal 
cord — exposed  by  the  erosions  of  ver- 
tebrae. 

The  adjacent  organs,  as  well  as  the 
connective  tissue  forming  the  immediate 
seat  of  the  tumor,  being  hyperaemic,  the 
blood  is  nnaerated  if  great  pressure 
occurs,  and  cyanosis  of  the  face,  with 
varicosity  of  the  veins  of  the  chest  and 
neck,  occurs.  The  lymphatic  glands  of 
the  neck  are  enlarged,  especially  the  sub- 
clavicular. 


Pressure  upon  the  oesophagus  causes 
dysphagia,  and  at  times  ulceration  into 
the  oesophagus.  The  ulceration  may 
occur  between  the  tiimor  and  the  trachea 
or  thoracic  duct. 

The  pulse  is  unequal;  there  is  dull- 
ness of  a  fixed  area  near  the  sternum  or 
clavicle,  and  often  a  distinct  ©edematous 
condition  of  the  arms,  neck,  and  chest: 
so  that  the  arms  may  measure  more  in 
the  circumference  than  the  legs.  Dis- 
placement of  the  heart-  or  lung-  tissue 
occurs.  Dyspnoea  soon  shows  itself,  but 
not  to  the  extent  that  it  does  in  pleu- 
risy or  empyema.  Pain  from  motion,  if 
adhesions  are  interfered  with,  may  occur 
in  some  cases;  but  ordinarily  very  little 
pain  is  present.  Exophthalmos  is  a  fre- 
quent symptom,  when  the  thyroid  is  in- 
volved in  the  tumor.  Xervousness:  the 
patient  will  often  be  unable  to  locate  the 
seat  of  inconvenience. 

Literature  of  'd6-'97-'9$. 

The  special  features  of  mediastinal 
tumors  may  be  illustrated  by  the  follow- 
ing cases: — 

Case  /. — The  tumor  gradually  en- 
croached upon  the  heart  so  as  to  displace 
it  one  inch  and  a  half  to  the  left  of  it- 
usual  site.  Temperature  varied  between 
1)0°.  100°.  and  102°.  The  pulse  was  7(i. 
The  left  lung  was  collapsed  and  the 
seiaoraph  showed  a  shadow  from  the 
second  rib  to  the  diaphragm  and  from 
two  inches  to  the  left  of  the  sternum  to 
the  left  border  of  the  chest.  Aphonia 
supervened  and  the  lungs  were  more  and 
more  collapsed.  The  left  bronchial  tube 
w  as  occluded.  The  patient  was  improved, 
but  not  cured,  by  the  use  of  chloride  of 
calcium  combined  with  iodide  of  potas- 
sium. A  dosage  ranging  from  10.  1.").  to 
20  grains  of  the  former  was  added  to  3 
grains  of  iodide  of  potassium.  The  latter 
drug  could  not  be  tolerated  in  doses  of 
7  Vs  grains.  E.  Fletcher  [ngals  ("Inter- 
national C  linics."  *<)7i. 

Case  of  hemorrhagic  adenochondrosar- 
coma  of  the  anterior  mediastinum  arising 


MEDIASTINUM.    TUMORS.  DIAGNOSIS. 


549 


from  the  thymus  gland,  in  a  man  of  20 
years.  He  had  shown  swelling  of  face, 
neck,  and  left  arm:  dullness  between  the 
sternum  and  in  the  left  infraclavicular 
fossa,  near  the  sternum  as  far  down  as 
the  third  costal  cartilage.  There  was 
bronchial  breathing-  near  the  root  of  the 
left  lung  and  enlarged  veins  over  the 
front  of  the  sternum.  The  apex-beat  was 
felt  on  admission,  but  soon  ceased  to  be 
palpable,  and  the  heart-sounds  became 
extremely  distant.  Later  there  was  dull- 
ness and  loss  of  breath-sounds  over  the 
left  lung,  but,  as  effusion  was  suspected, 
paracentesis  was  performed  in  the  left  , 
midaxillary  line,  and  40  ounces  of  blood- 
stained fluid  withdrawn  from  a  distended 
pericardium.  This  gave  relief,  but  the 
patient  became  more  dyspnceie  and  deliri- 
ous, and  eventually  died  two  months 
after  admission.  At  the  autopsy  a 
growth  was  found  occupying  the  supe- 
rior and  anterior  mediastinum  and  cover- 
ing over  half  of  the  pericardium,  to  which 
it  was  adherent.  H.  13.  Rolleston  (Jour, 
of  Path,  and  Bact..,  Jan..  '97). 

Diagnosis.  —  The  symptoms  which 
have  been  mentioned  may  serve  the 
purpose  of  differentiating  tumors  of  the 
mediastinum  from  abscesses  if  there  is 
not  present  pain,  chills  and  fever,  ele- 
vated temperature,  or  very  marked  ema- 
ciation or  apparent  ill  health.  The  age 
is  also  a  means  of  determining  upon  a 
correct  diagnosis.  Benign  or  malignant 
tumors  of  the  mediastinum  may  occur 
at  any  age,  hut  aneurismal  tumors  usu- 
ally occur  after  the  age  of  forty-five. 

The  male  and  female  suffer  equally, 
though  our  own  cases  have  been  female. 
Record  of  134  cases  of  mediastinal  can- 
cer. 98  cases  of  sarcoma,  115  cases  of  ab- 
scess, 16  cases  of  non-suppurative  inflam- 
mation, 21  cases  of  lymphoma,  7  cases  of 
fibroma,  (i  cases  of  haematoma,  11  der- 
moid cysts.  8  hydatid  cysts,  and  KM  eases 
of  various  mediastinal  diseases.  Con- 
clusions: I.  Cancer  is  more  frequently 
found  in  the  mediastinal  spaces  than  any 
other  morbid  process.  2.  Abscess  is  the 
morbid  process  next  in  frequency  of  oc- 
currence.   3.  Sarcoma  occupies  the  third 


position  as  to  frequency  of  occurrence. 
4.  Lymphomata  and  lymphadenomata 
occupy  a  fourth  place,  but  are  much  more 
rare  than  the  others  mentioned.  5.  The 
anterior  mediastinum  is  affected  far  more 
frequently  than  the  other  two  spaces. 
6.  Most  mediastinal  growths  occur  in 
adults.  7.  More  males  are  affected  by 
forms  of  mediastinal  disease  than  fe- 
males. 8.  Cancer  and  sarcoma  of  this 
space  are  necessarily  fatal.  !>.  About  40 
per  cent,  of  the  cases  of  abscess  recover. 
Hare  ( "Fothergillian  Essay."'  '89). 

Cancer  of  the  mediastinum,  despite  the 
statistics  of  Hare,  are  nothing  like  as  fre- 
quent as  sarcoma  of  that  region,  or  espe- 
cially lymphosarcoma.  Steven  (Glasgow 
Med.  Jour.,  June,  Aug.,  "91 ). 

Eeview  of  67  cases  of  carcinoma  of  the 
mediastinum  in  children  found  in  litera- 
ture. As  compared  to  adults,  sarcoma  is 
the  most  frequent  morbid  process,  car- 
cinoma next,  and  abscess  third  in  order. 
Edwards  (Archives  of  Ped.,  July,  '89). 

Eight  cases  of  primary  malignant 
growth  of  the  anterior  mediastinum. 
The  patients  were  all  over  40,  with  the 
single  exception  of  a  woman  aged  23. — a 
very  acute  case  of  carcinoma.  Two  were 
over  60.  The  history  of  illness  dated 
from  not  more  than  six  months.  The  dis- 
ease was  accompanied  by  pleural  effusion 
in  4  cases,  purulent  in  1.  and  chylous  in 
another.  Letulle  (Archives  Gen.  de  Med.. 
Dec,  "90). 

Case  of  carcinoma  of  the  mediastinum 
in  a  young  woman  27  years  of  age.  The 
patient  died  of  cyanosis,  the  diagnosis  of 
tuberculosis  having  been  made.  The 
autopsy  showed  the  mistake:  also  a  neo- 
plasm, which  occupied  the  anterior  and 
superior  part  of  the  mediastinum.  His- 
tological examination  revealed  carci- 
noma of  fibrous  stroma,  well  developed, 
presenting  nothing  special.  Tissier  (Bull, 
de  la  Soc.  Anat..  Dec.  20,  '89). 

Case  diagnosed  as  aneurism  of  the  aorta 
with  paralysis  of  the  recurrent,  but  which 
at  the  post-mortem  examination  proved 
to  be  a  mediastinal  carcinoma.  In  mak- 
ing a  differentia]  diagnosis  between  the 
two  affections,  it  must  be  noted  that 
paralysis  of  the  recurrent,  due  to  a 
mediastinal  tumor,  develops  gradually. 
Hoarseness  sets  in,  but  again  passes  off, 


550 


MEDIASTINUM.    TREATMENT  OE  MEDIASTINAL  DISORDERS. 


and  a  paresis  can  be  demonstrated  only 
after  a  considerable  time.  In  aneurism 
the  paralysis  of  the  vocal  cord  is  often 
the  first  symptom.  Haemorrhages  are  al- 
ways an  indication  of  the  approacning 
end  in  aneurism,  while  in  tumors  there  is 
not  infrequently  haemoptysis  at  an  earlier 
date.  Schadewaldt  (Laryn.  Soc.  of  Ber- 
lin, '95). 

Literature  of  'dG-'dl-'dS. 

Case  of  steel-dust  deposit  in  the  medi- 
astinum. The  steel  was  inhaled  during 
work  in  a  factory  and  caused  consider- 
able inflammation  within  the  chest; 
gradually  discharged  from  a  sinus  in  the 
jugular  fossa.  Sciagraph  showing  opaque 
areas  in  the  mediastinal  space.  M.  W. 
Bacon  (Phila.  Med.  Jour.,  Feb.  19,  '98). 

Prognosis.  —  Early  treatment  may 
cause  a  subsidence,  if  not  a  disappear- 
ance, of  the  disease. 

Demantke  has  put  on  record  a  case 
of  tumor  of  the  mediastinum  of  very 
short  duration.  It  occurred  in  a  man 
aged  26.  He  died  of  suffocation,  and 
the  autopsy  showed  the  tumor  to  have 
rested  on  the  pericardium  below,  and  to 
have  extended  up  into  the  neck  about 
the  level  of  the  clavicle. 

Treatment. — Tumors  of  the  medias- 
tinum call  for  treatment  according  to 
the  etiology  of  the  disease  present. 

Syphilitic  tumors  require  antisyphi- 
litic  medication.  The  most  serious  ob- 
stacles to  operative  intervention  are  en- 
countered, but  when  a  trap-door  allows 
free  access  to  the  mediastinum,  and  the 
X-ray  serves  to  diagnosticate  bullets  and 
tumors,  great  advance  has  been  made 
toward  the  exploration  of  the  important 
portion  of  the  body,  and  we  may  hope 
for  the  removal  of  tumors. 

Treatment  of  Mediastinal  Disorders. 

Surgical. — Operative  procedures  may 
be  carried  into  the  various  portions  of 
this  division  of  the  thorax  with  a  fair 
prospect  of  affording  relief  to  some  path- 


!  ological  conditions  heretofore  regarded 
beyond  the  reach  of  surgery.  Experi- 
mentation on  animals,  though  not  a  suf- 
ficient test,  has  still  demonstrated  the 
feasibility  of  surgical  interference  in 
this  comparatively-unexplored  region. 
"If  animals  can  survive  the  traumatism  of 
entering  the  mediastinum  from  the  front 
and  rear  of  the  thorax,  as  has  been  veri- 
fied by  experiments  of  Le  Moyne  Wills, 
De  Forest  Willard;  Levy,  of  Berlin;  and 
Zakharevitch,  of  Russia;  it  is  evident 
that  operations  may  be  undertaken  for 
the  relief  of  mediastinal  tumors,  hy- 
datids, and  other  morbid  growths  of  this 
space. 

Clinical  observation  upon  the  human 
subject  has  shown  that  diseased  struct- 
ures of  the  chest,  as  in  other  parts  of 

j  the  physical  organism,  are  more  tolerant 
of  surgical  interference  than  in  trauma- 
tism of  the  contents  of  the  thorax  in 
their  normal  condition.  It  is  therefore 
inferred  that  the  operations  upon  the 
thoracic  walls,  and  upon  the  tissues  of 
the  lung  under  abnormal  conditions 
which  are  indicated,  will  be  warranted 
in  all  such  cases  as  have  proved  safe  in 

I  the  experiments  upon  dogs  and  rabbits. 
On  the  other  hand,  it  is  not  a  necessary 
consequence  that  operations  upon  the 
diseased  structures  of  the  chest  in  the 
human  subject  shall  prove  hazardous,  be- 
cause experiments  on  inferior  animals 
in  a  healthy  state  have  been  unsatisfac- 
tory or  have  turned  out  unfavorably. 

[The  senior  editor  has  proposed  an  im- 
proved method  for  exploring  the  thoracic 
cavity.  R.  F.  Weir  and  J.  D.  Bryant 
have  proposed  openings  into  the  medias- 
tinum from  the  rear,  while  the  operations 
of  Jennings,  Lowson,  and  Delorme  con- 
template the  exposure  of  the  contents 
from  the  front,  but  by  the  section  of  ribs 
at  both  sternal  and  lateral  extremities, 
according  to  the  incisions  in  the  skin- 
flap.  The  improvement  that  is  expected 
to  be  accomplished  is  in  only  one  section 


MEDIASTINUM. 

of  the  bones,  using  the  cartilages  of  the 
ribs  for  hinges. 

The  arm  upon  the  side  to  be  examined 
should  be  raised  above  the  head.  An 
incision  is  made  in  the  midaxillary  line, 
directly  downward,  from  the  third  to  the 
eighth  rib,  inclusive  or  exclusive,  as  the 
case  may  warrant,  with  the  division  of 
the  ribs  either  with  the  saw  or  bone- 
cutter,  extending  to  the  pleural  lining 
without  dividing  it.  Temporary  means 
of  arresting  haemorrhage  should  be  em- 
ployed, and  afterward  there  should  be  a 
transverse  incision  carried  forward  from 
the  upper  extremity  of  the  perpendicular 
along  the  upper  border  of  the  third  or 
fourth  rib,  and  another  from  the  lower 
extremity  along  the  upper  border  of  the 
seventh  or  eighth  rib,  as  may  be  requisite, 
extending  in  front  to  the  costal  cartilage. 
Any  bleeding  should  be  controlled  before 
dividing  the  parietal  pleura,  in  making 
either  of  these  incisions.  Scissors  which 
have  a  blunt  point  on  the  internal  blade 
may  be  used  for  dividing  the  pleura  on 
each  line,  and,  if  the  lungs  have  not  col- 
lapsed previously,  this  will  occur  upon 
the  entrance  of  the  air  into  the  chest. 
J.  McFadden  Gaston,  Sr.  and  Jr.] 

Literature  of  '96-'97-'98. 

Considerable  areas  of  the  sternum  can 
be  resected  with  impunity.  Seventeen 
cases  collected  in  which  masses  of  the 
sternum  were  removed  for  various  dis- 
eases. Personal  cases:  One  of  resection 
of  the  manubrium,  inner  third  of  the  left 
clavicle,  and  lower  third  of  the  left 
sterno-cleido-mastoid  for  sarcoma.  The 
second  case  was  one  of  carcinoma  of  the 
breast  with  secondary  carcinoma  of  the 
sternum  at  the  junction  of  the  manu- 
brium and  gladiolus.  Both  breasts  were 
successfully  removed,  and  resection  of 
parts  of  the  manubrium  and  gladiolus 
was  followed  by  recovery  from  the  opera- 
tion; but  death  from  recurrence  of  the 
trouble  occurred  subsequently.  W.  W. 
Keen  (Med.  and  Surg.  Rep.,  Mar.,  '97). 

Medical  Treatment.  —  The  use  of 
chloride  of  calcium  in  glandular  enlarge- 
ments of  the  neck  lias  been  recommended 
by  Thomas  J.  Mays,  and  is  a  corrobora- 


MENINGITIS.  551 

|  tion  of  the  confident  use  of  it  in  cases  of 

I  mediastinal  tumors. 

Arsenic  is  also  useful.  It  may  be  com- 
bined with  mercurials,  iodides,  such  as 
in  the  preparation  known  as  Donovan's 
solution. 

Medical  treatment  may  lead  to  retro- 
gression or,  at  least,  the  arrest  of  such 
growths  when  benign.    Arsenic  must  be 
given  the  first  rank,  and  iodide  of  potas- 
sium in  increasing  doses  and  for  a  long 
enough  time  to  judge  of  its  effects  in 
doubtful  cases,  as  syphilis  is  always  to 
be  thought  of.    Millot  Carpentier  (Revue 
Inter,  de  Med.  et  de  Chir.,  Feb.  10,  '95): 
Inoperable  mediastinal  tumors  may  be 
successfully  treated  by  means  of  electrol- 
ysis and  cataphoresis,  using  the  nega- 
tive pole  when  and  where  dissolution  is 
needed  and  the  positive  with  Donovan's 
solution  where  the  cataphoric  action  of 
the  drug  is  expected. 

The  exact  diagnosis  may  not  always 
be  made,  but  the  case  may  be  treated  in 
this  way  when  the  typical  symptoms  give 
presumptive  evidence  of  sarcoma  of  the 
mediastinum.  Less  encouragement  is 
promised  for  carcinoma. 

J.  McFadden  Gaston, 

J.  McFadden  Gaston,  Jr., 

Atlanta. 

MEDITERRANEAN    FEVER.  See 

Malarial  Fevers. 

MELANCHOLIA.    See  Insanity. 

MENIERE'S  DISEASE.  See  In- 
ternal Ear. 

MENINGITIS.— Gi\,  urjny^  mem- 
brane; iTig. 

Meningitis  (Cerebral). 

Varieties. — Cerebral  meningitis  means 
inflammation  of  the  meninges  of  the 
brain. 

Pachymeningitis  means  inflammation 


552 


M  EN  [NGITIS.    EXTERNAL  PACHYMENING ITIS  (CEREBRAL) . 


cf  the  dura  mater.  Pachymeningitis  is 
external  or  internal,  and  acute  or  chronic 
in  its  duration. 

Leptomeningitis  means  inflammation 
of  the  soft  membranes,  the  arachnopia. 
The  term  ^arachnopia"  is  here  used  to 
denote  the  pia  mater  and  the  so-called 
arachnoid  membrane,  which  are  always 
involved  together  in  leptomeningitis. 
Leptomeningitis  occurs  as  an  acute  or 
chronic  disease,  and  when  acute  includes 
many  etiological  varieties,  while  the 
.causes  producing  chronic  leptomeningitis 
are  much  more  obscure. 

It  will  be  convenient  to  consider  the 
subject  of  meningitis  in  the  order  indi- 
cated above,  all  the  etiological  varieties 
of  acute  leptomeningitis  being  included 
in  the  description  of  that  disease.  In- 
flammation of  either  membrane  may 
spread  to,  and  include  the  others;  or 
the  brain-substance  itself,  constituting  a 
meningoencephalitis. 

External  Pachymeningitis  (Cerebral). 

Definition. — External  pachymeningitis 
means  inflammation  of  the  external  layer 
of  the  dura  mater.  It  is  almost  always 
secondary,  and  almost  never  a  primary 
affection. 

Symptoms. — The  symptoms  of  external 
pachymeningitis  are  usually  of  very  in- 
definite character,  and  vary  according  to 
the  position,  extent,  and  grade  of  the 
dural  inflammation.  When  it  follows 
traumatism  there  may  be  intense  head- 
ache, nausea,  vomiting,  delirium  chang- 
ing into  coma,  local  or  general  spasms, 
and,  finally,  unless  relief  is  afforded,  the 
collection  of  pus  may  cause  more  decided 
signs  of  septic  infection  and  increased 
intracranial  tension.  In  all  cases  the 
condition  of  the  ears  should  receive  the 
most  careful  scrutiny,  since  many  of  the 
cases  are  associated  with  suppurative 
aural  disease.  As  the  symptoms  in  them- 
selves are  by  no  means  conclusive  in  their 


character,  or  in  the  mode  of  their  devel- 
opment, a  very  careful  study  should  be 
made  of  all  the  possible  causes  whenever 
this  condition  is  suspected  to  exist. 

Literature  of  '96-'97-'98. 

Case  of  "wound  of  the  eyeball  which 
became  septic  and  after  enucleation 
death  ensued  from  meningitis  ten  days 
after  the  operation.  Bacteriological  ex- 
amination of  the  purulent  exudation 
demonstrated  the  presence  of  the  diplo- 
coccus  pneumoniae.  Lapersonne  (  L'Echo 
Med.  du  Xord,  May  !).  '97). 

Six  thousand  five  hundred  and  eighty 
eyes  excised  at  Moorfields  Hospital, 
among  which  eight  fatal  cases  have  in- 
curred. From  report  of  five  of  these 
cases  with  autopsies  and  microscopical 
examinations,  the  following  conclusions 
are  reached:  — 

1.  Meningitis  may  be  present  for  a  cer- 
tain time  without  there  being  sufficient 
symptoms  to  enable  one  to  diagnosticate 
the  disease. 

1.  Meningitis  has  been  known  to  follow 
other  operations  besides  the  excision  of 
suppurating  eyes,  and  cases  are  also 
recorded  in  which  the  excision  of  an  eye 
which  was  not  suppurating  has  been  fol- 
lowed by  death  from  meningitis. 

3.  The  changes  seen  in  many  cases  in 
dicate  that  the  disease  is  of  older  stand- 
ing than  the  symptoms  would  appear  to 
indicate. 

4.  Infection  may  .occur  at  any  time 
from  an  eye  which  is  suppurating,  and 
the  longer  the  pus  is  shut  up  in  the  eye 
the  greater  is  the  risk  and  the  greater 
will  be  the  absorption  of  products  of  sup- 
puration. 

5.  There  are  two  ways  in  which  men- 
ingitis may  arise:  (a)  by  direct  exten- 
sion along  the  optic  nerve  and  structures 
passing  through  the  sphenoidal  fissure; 
(/>)  by  infective  material's  being  carried 
along  the  vessels. 

(i.  The  sooner  the  pus  is  got  rid  of  the 
better:  and.  if  it  is  thought  not  desirable 
to  excise  the  eye.  it  should  be  at  once 
opened,  the  contents  completely  removed, 
the  sclerotic  thoroughly  scrubbed  out. 
and  both  it  and  the  surrounding  parts 
remh  red  a  sept  ie. 


MENINGITIS.    EXTERNAL  PACHYMENINGITIS  (CEREBRAL). 


553 


7.  As  the  products  of  putrefaction  may 
have  soaked  into  the  sclerotic  and  in- 
fected the  surrounding  parts,  it  is  far 
better  to  remove  it;  good  drainage  is 
then  insured,  and  every  piece  of  useless 
and  suppurating  tissue  is  removed.  C.  D. 
Marshall  (Royal  London  Ophthal.  Hosp. 
Rep.,  vol.  xiv,  p,  305,  "97). 

A  senile  form  of  external  pachymenin- 
gitis, running  a  more  or  less  chronic 
course,  is  observed  among  chronic  alco- 
holic subjects  and  those  who  have  pre- 
viously had  syphilis  or  certain  infectious 
diseases,  such  as  erysipelas  of  the  head. 
The  symptoms  present  in  such  cases  are 
those  of  senility  with  headache,  usually 
vertical  in  position. 

literature  of  '96-'97-'98. 

Case  of  meningitis  due  to  streptococci 
and  secondary  to  facial  erysipelas.  Fluid 
removed  by  lumbar  puncture  twenty-four 
hours  before  death  gave  pure  culture  of 
streptococci.  Examination  of  the  blood 
was  negative.  Jemma  (Gaz.  degli  Osped. 
e  delle  Clin.,  No.  06,  '90). 

Diagnosis. — The  diagnosis  of  external 
pachymeningitis  can  only  be  made  by  a 
careful  study  of  the  antecedent  or  asso- 
ciated conditions  to  which  the  affection 
is  commonly  secondary.  The  symptoms 
which  may  be  present  in  these  cases  are 
simply  those  of  cerebral  irritation,  and, 
in  some  cases,  of  cerebral  compression, 
to  which  are  added  the  general  signs  of 
the  existence  of  a  septic  condition  in  the 
cases  in  which  pus  is  formed.  In  cases 
running  a  more  or  less  acute  course  the 
diagnosis  will  be  made  by  a  careful  study 
of  the  history  of  the  illness  and  of  the 
associated  conditions  found  upon  exam- 
ination of  the  patient.  The  history 
should  especially  refer  to  any  traumatism 
or  syphilitic  infection.  In  the  chronic 
senile  cases  the  diagnosis  must  he  largely 
inferential,  when  persisteni  dull  head- 
ache is  associated  with  mental  deteriora- 


tion and  a  history  of  alcoholism  or  syph- 
ilis. 

Etiology.  —  External  pachymeningitis 
is  commonly  associated  with  traumatism, 
sun-stroke,  caries  of  the  flat  bones  of  the 
cranium,  purulent  aural  disease,  syphilis, 
erysipelas,  and  probably  certain  other 
acute  infections.  Traumatism  and  caries 
of  the  cranial  bones  are  the  chief  etio- 
logical factors  producing  inflammation  of 
the  external  layer  of  the  dura  mater. 

Pathology. — Post-mortem  examination 
in  these  cases  reveals  very  often  great 
thickening  of  the  bones,  especially  of  the 
inner  table  of  the  skull,  and  a  collection 
of  pus  between  the  bone  and  the  dura 
mater.  In  the  syphilitic  cases  this  thick- 
ening of  the  bone  is  often  very  marked. 
Osier  refers  to  a  case  at  the  Montreal 
General  Hospital  in  which  the  frontal 
lobes  were  so  compressed  by  thickened 
bone  and  purulent  effusion  that  the  ante- 
rior vertical  measurement  of  the  brain 
was  only  2.5  centimetres,  while  the  simi- 
lar posterior  measurement  was  8,  centi- 
metres. In  other  cases  the  bone  is 
slightly,  if  at  all,  affected,  while  there  is 
considerable  thickening  of  the  dura 
mater,  consisting  of  a  partially-organized 
connective  tissue,  which  may  be  softened 
and  broken  down  in  particles.  This  con- 
dition is  chiefly  observed  in  senile  sub- 
jects, and  is  usually  associated  with  wide- 
spread vascular  degeneration.  During 
my  residence  at  the  Morris  Plains  Hos- 
pital several  such  eases  came  under  ob- 
servation, and  I  have  no  doubt  but  that 
the  post-mortem  records  of  the  hospitals 
for  the  insane  will  reveal  this  lesion  as 
quite  common  among  the  chronic  and 
senile  insane. 

Prognosis. — The  prognosis  is  always 
grave,  and  especially  so  in  cases  affecting 
old  subjects.  When,  in  purulent  cases 
due  to  traumatism,  the  collection  of  pus 
is  evacuated  and  drained  by  the  use  of 


554 


MENINGITIS.    INTERNAL  PACHYMENINGITIS  (CEREBRAL). 


the  trephine,  the  outlook  is  better,  and  a  I 
final  cure  results  in  some  cases.  The 
syphilitic  form  is  often  remarkably  im- 
proved by  specific  treatment. 

Treatment. — The  treatment  of  exter- 
nal  pachymeningitis  must  include  that 
of  the  primary  condition  giving  rise  to 
it.  When  suppuration  occurs  after  trau- 
matism, the  trephine  should  be  used  with 
the  hope  of  curing  the  patient,  if  the 
operation  is  done  early  and  before  the 
brain  becomes  affected  by  serious  con- 
gestion or  inflammation. 

The  cases  resulting  from  syphilis 
should  be  treated  actively  with  anti- 
syphilitic  remedies,  and,  if  the  general 
strength  of  the  patient  permit,  large 
doses  of  potassium  iodide  should  be  given 
with  the  bichloride  of  mercury.  The 
senile  cases  demand  careful  regulation  of 
the  digestion,  the  use  of  general  tonic 
measures,  and  the  relief  of  pain. 

Internal  Pachymeningitis,  Cerebral 
(Hemorrhagic  Internal  Pachymeningi-  I 
tis;  Hematoma  of  the  Dura  Mater). 

Definition. — Internal  pachymeningitis 
means  inflammation  of  the  internal  sur- 
face of  the  dura  mater.  It  is  almost 
always  a  chronic  affection,  and  is  far 
more  common  in  hospitals  for  the  insane 
than  in  general  hospitals  or  in  private 
practice.  Osier  states  that  during  ten 
years  he  saw  no  case  of  this  kind  at  the 
Montreal  General  Hospital,  but  while  at 
the  Philadelphia  Hospital  four  cases  were 
observed  by  him  within  a  period  of  three 
months.  The  pathological  meaning  of 
the  lesions  found  in  this  disease  is  still 
a  matter  of  dispute,  some  authorities 
contending  that  they  are  primarily  hem- 
orrhagic; while  others  believe,  with  Vir-  ! 
chow,  who  first  accurately  described  the 
condition,  that  they  are  primarily  in- 
flammatory. The  weight  of  the  evidence 
seems  to  the  writer  to  be  upon  the  side 
of  the  theory  of  their  inflammatory  ori- 


gin, while  it  is  to  be  admitted  that  cer- 
tain cases  appear  to  arise  from  haemor- 
rhage. The  disease  occurs  in  old  age, 
or  in  those  who  have  lived  dissipated 
lives,  and  are  prematurely  aged  in  conse- 
quence. 

Symptoms. — The  symptoms  of  hemor- 
rhagic internal  pachymeningitis  will  vary 
according  to  the  extent  of  the  lesion, 
which  is  usually  bilateral.  There  may 
be  paresis  or  paralysis,  vertigo  or  apo- 
plectic seizures,  dull  or  sharp  pains  in 
the  head,  mental  hebetude  or  stupor,  in- 
equality of  the  pupils,  spastic  paralysis 
of  one  or  more  limbs,  and,  as  the  case 
progresses,  acute  exacerbations  of  symp- 
toms occur  from  time  to  time.  Some 
writers  mention  optic  neuritis,  conjugate 
deviations  of  the  eyeballs,  and  nystagmus 
as  symptoms  of  this  condition.  All  of 
the  symptoms  are  very  varied  and  irregu- 
lar in  development  in  different  cases,  and 
from  this  fact  their  true  nature  is  only 
rarely  suspected  during  life.  During  the 
intervals  between  the  more  acute  seiz- 
ures, which  are  usually  apoplectic  in 
nature,  the  patient  may  enjoy  good  gen- 
eral health,  and  only  in  the  later  stages 
of  the  disease  present  continuous  symp- 
toms. Severe  epileptiform  convulsions 
are  sometimes  marked  features  of  these 
cases,  having  been  observed  by  the  writer 
in  two  cases  which  presented  character- 
istic post-mortem  lesions. 

In  1500  autopsies  pachymeningitis  in- 
terna hemorrhagica  met  with  in  only  4 
instances.  In  3  of  the  4  cases  death  re- 
sulted from  prolonged  convulsions,  the 
fourth  dying  from  an  acute  enteritis, 
with  no  symptomatic  evidences  of  the 
pachymeningitis  except  restlessness  and 
slight  rigidity.  In  none  of  the  4  cases 
M  as  there  noted  any  paralysis.  Xorthrnp 
(Med.  Record,  Aug.  3.  '90). 

Speech  is  often  slow,  the  mind  fails 
more  or  less  rapidly,  and  there  may  be 
acute  maniacal  attacks.    According  to 


MENINGITIS.    INTERNAL  PACHYMENINGITIS  (CEREBRAL) 


000 


certain  writers,  hemorrhagic  internal 
pachymeningitis  may  occur  as  an  acute 
disease  in  rachitic  children,  but  such  le- 
sions must  be  extremely  rare. 

Extensive  internal  hsemorrhagic  pachy- 
meningitis found  in  an  anaemic  and 
emaciated  infant  23  months  old.  North- 
rup  (Med.  Rec,  May  10,  '90). 

Finally  cases  presenting  wide-spread 
bilateral  lesions  of  this  disease  have  been 
observed  by  the  writer  in  which  none  of 
the  above  symptoms  were  noted  during 
life. 

Diagnosis. — The  symptoms  are  so  in- 
definite that  a  positive  diagnosis  is  im- 
possible. The  majority  of  the  cases  are 
diagnosed  on  the  post-mortem  table. 
Persistent  dull  headache  of  the  vertex, 
with  mental  hebetude  and  a  history  of 
apoplectic  seizures  at  irregular  intervals, 
with  or  without  some  form  of  spasm  or 
paralysis,  may  cause  us  to  suspect  this 
lesion,  especially  when  these  symptoms 
appear  toward  the  close  of  a  broken-down 
and  dissipated  life. 

Case  of  pachymeningitis  in  a  man,  aged 
25,  who  had  suffered  for  two  months 
from  severe  headache,  and  who  was 
brought  to  the  hospital  comatose,  with 
right  hemiplegia  and  contracture,  with 
increased  reflexes. 

Death  in  seventy  hours.  Autopsy  re- 
vealed new  formation  of  membrane  be- 
tween dura  and  pia  on  left  side  in  frontal 
region,  with  one  remarkably-large,  young 
blood-vessel,  which  had  doubtless  given 
rise  to  the  large  intermeningeal  haemor- 
rhage, two  and  one-half  ounces  of  which 
were  found.  Duponchel  (Le  Bull.  Med., 
Aug.  5,  '88). 

Etiology. — This  disease,  as  has  already 
been  remarked,  occurs  chiefly  among  the 
insane  and  the  subjects  of  other  chronic 
nervous  diseases.  Usually  the  subjects 
affected  are  old  or  prematurely  broken 
down  by  alcoholism,  syphilis,  or  tuber- 
culosis, or  by  prolonged  dissipation  of 
various  kinds.    By  far  the  majority  of 


cases  occur  in  men.  It  is  quite  often 
found  associated  with  general  paralysis 
of  the  insane,  and  is  more  often  still 
observed  post-mortem  in  cases  of  ter- 
minal dementia  in  which  no  symptoms 
indicative  of  its  presence  were  observed 
during  life. 

Traumatism  and  sun-stroke  are  thought 
by  some  to  be  causes  of  this  affection; 
but  from  its  very  chronic  nature,  and  the 
fact  that  it  usually  occurs  in  old  age, 
exact  information  is  very  often  wanting, 
and  the  connection  between  antecedent 
traumatism  or  sun-stroke  impossible  to 
trace.  There  is  little  doubt,  however, 
that  both  of  these  causes  may  contribute 
some  of  the  cases. 

Case  of  hsemorrhagic  pachymeningitis 
in  a  man,  aged  57,  who  was  thrown  from 
a  tricycle  with  great  force  on  his  head 
and  shoulders.  Complete  recovery.  W.  B. 
Goldsmith  (Amer.  Jour.  Insanity,  June 
15,  '88). 

The  most  important  causes  clinically 
are  those  which  predispose  to  eaily  de- 
generative changes  in  the  blood-vessel 
walls,  and  to  a  general  weakened  condi- 
tion of  the  normal  resistive  powers  of 
the  bodily  tissues.  Heredity  probably 
plays  an  important  part  in  the  genesis 
of  these  cases,  in  common  with  its  in- 
fluence in  determining  insanity  and  nerv- 
ous diseases  in  general. 

Pathology. — The  macroscopical  lesions 
observed  post-mortem  are  thin  or  thick, 
highly-vascular,  subdural  membranes, 
usually  bilateral,  and  limited  more  fre- 
quently to  the  parietal  regions,  although 
they  may  extend  much  beyond  these  lim- 
its. Within  or  beneath  the  substance  of 
this  poorly-organized  membrane  there 
may  be  found  a  large  clot,  but  numerous 
fine  capillary  haemorrhages  are  more 
commonly  met  with.  In  some  of  the 
cases  no  haemorrhage  is  to  be  seen,  and 
in  these  cases  there  is  onlv  the  more  or 


550 


M  ENIN<  JITIS.    1  INTERNAL  PACHYMENINGITIS  (CEREBRAL). 


less  firm  fibroid  membrane,  containing 
numerous  blood-vessels  and  lying  in  con- 
tact with  the  under  surface  of  the  dura 
mater,  over  the  vertex  of  the  brain. 
Sometimes  this  membrane  is  divisible 
into  several  apparent  layers,  as  of  several 
successive  accessions  of  growth;  in  other 
cases  it  is  merely  a  very  thin  vascular 
membrane,  stained  brownish  or  reddish 
from  more  or  less  recent  capillary  effu- 
sions of  blood.  When  large  collections 
of  blood  are  found,  they  are  often  en- 
cysted within  layers  of  false  membrane, 
and  the  blood  is  partially  broken  down, 
and  pus  may  even  be  formed  in  some 
cases.  The  membrane  which  is  supposed 
to  be  the  initial  lesion  of  this  condition 
is  undoubtedly  of  dural  origin  and  de- 
rives its  blood-vessels  from  the  dural 
vessels.  It  should  be  remembered,  how- 
ever, that  so  good  an  authority  as  Bevan 
Lewis  believes  that  the  haemorrhage  is 
the  primary  lesion  and  that  the  mem- 
branes are  formed  from  organization  of 
the  effused  blood.  The  view  of  Virchow 
is,  however,  more  generally  accepted  at 
the  present  time,  and  that  is  that  the 
membrane  is  the  product  of  inflamma- 
tion and  that  the  haemorrhages  found 
are  distinctly  secondary  to  the  poorly- 
formed  inflammatory  membranous  exu- 
date. The  cases  which  show  very  hard 
fibrous  membranes  without  any  appear- 
ance of  haemorrhage  tend  to  support  the 
theory  of  inflammation. 

Literature  of  '96-'97-'9%. 

Two  cases  of  hemorrhagic  internal 
pachymeningitis  in  children.  Hemor- 
rhagic pachymeningitis  is  a  lesion  thai 
should  be  though!  of  whenever  convul- 
sions and  unnatural  rigidity,  with  deep- 
ening coma,  occur  in  a  rachitic  or  ca- 
chectic child,  under  one  year  of  age.  The 
new  membrane  mus1  be  regarded  as  origi- 
nating from  the  proliferation  of  dural 
endothelial  cells,  or,  more  probably,  from 

the  subendothelial  connective-tissue  cells. 


The  new  cellular  connective  tissue  is  ex- 
ceedingly likely  to  be  the  seat  of  develop- 
ment of  new  blood-vessels  with  thin 
walls.  Even  in  cases  that  may  be  sup- 
posed to  have  originated  from  haemor- 
rhage, an  intimate  connection  must  he 
recognized  between  the  organization  of 
the  clot  and  the  proliferation  of  dural  con- 
nective-tissue cells.  In  some  cases  there 
seems  to  be  little  inclination  to  hemor- 
rhage; in  others  there  are  numerous, 
punctate  hemorrhages  from  the  delicate 
vascular  membrane.  The  membrane 
varies  in  thickness,  in  some  cases  being 
so  delicate  as  to  be  readily  overlooked,  in 
others  reaching  two  or  three  lines  in 
thickness.  C.  A.  Herter  (Ainer.  dour. 
Med.  Sci.,  Aug.,  "98). 

Prognosis. — The  prognosis  is  most  un- 
favorable. When  the  lesion  can  be  sus- 
pected it  is  not  usually  amenable  to  any 
known  treatment.  Especially  is  this  true 
after  paralytic  seizures  occur  and  the 
general  condition  of  the  patient  is 
broken  down  by  disease.  Death  usually 
occurs  from  a  general  failure  of  the  vital 
powers  or  acutely  in  one  of  the  apo- 
plectic or  convulsive  seizures. 

Treatment. — As  soon  as  the  affection 
is  suspected  the  constitution  of  the  pa- 
tient should  be  built  up  by  hygiene, 
tonics,  good  food,  rest,  and  every  possible 
means  used  to  increase  his  vitality.  Af- 
terward the  iodide  of  potassium  should 
be  given  in  small  doses  for  prolonged 
periods.  When  there  is  a  history  of 
syphilis,  larger  doses  should  cautiously 
be  given,  with  the  addition  of  small  doses 
of  mercury  in  the  form  most  acceptable 
to  the  stomach  of  the  patient. 

Precedence  given,  in  treatment  of  syphi- 
litic meningitis,  to  the  iodide  of  sodium. 
Nutritious  feeding  considered  mosl  im- 
portant. When  sedatives  are  required, 
paraldehyde  is  pre-eminently  indicated. 

Dauche/.  I  La  France  Med..  Sept.  12,  HO). 

The  treatment  of  the  acute  apoplectic 
and  convulsive  seizures  is  that  of  any 
intercranial  haemorrhage.     Perfect  rest. 


MENINGITIS.    ACUTE  LEPTOMENINGITIS. 


5  5  T 


ice-Lag  to  the  head,  with  full  doses  of 
chloral  and  opium  unless  they  are  con- 
tra-indicated by  other  diseased  condi- 
tions of  the  patient.  Leeches  are  men- 
tioned as  efficacious  by  some  writers. 
They  may  be  applied  to  the  temples  or 
to  the  mastoid.  The  writer,  however,  has 
used  blisters  to  the  nape  of  the  neck  or 
over  the  shaved  vertex,  with  seeming 
benefit  in  such  cases.  The  bromides  are 
also  useful,  in  combination  with  opium 
and  chloral,  in  controlling  mental  and 
motor  restlessness  during  the  convales- 
cence  from  the  attack. 

Acute  Leptomeningitis. 

Definition . — Acute  leptomeningitis, 
means  inflammation  of  the  arachnopia, 
the  vascular  and  nutritive  envelopes  of 
the  brain. 

Varieties. — Acute  inflammation  of  the 
soft  membranes  enveloping  the  brain 
occurs  from  a  variety  of  causes,  nearly 
all  of  which  operate  by  infection  of  these 
membranes.  In  location  and  extent  the 
inflammation  may  be  basilar,  cortical, 
unilateral,  or  general.  Very  many  path- 
ological and  etiological  varieties  of  men- 
ingitis are  described.  Pathologically 
acute  leptomeningitis  may  be  suppura- 
tive or  purulent,  nonsuppurative,  serous, 
tubercular,  syphilitic,  and  epidemic  cere- 
brospinal. Etiologically  the  disease  may 
be  classified  as  simple  (or  idiopathic), 
I  ran  malic,  and  infective.  The  infective 
group  includes  the  great  majority  of  the 
cases. 

General  Symptomatology. — The  symp- 
toms observed  in  cases  of  acute  lepto- 
meningitis will  depend  in  great  part 
upon  the  location  and  extent  of  the  in- 
flammation, while  very  often  its  symp- 
toms will  be  combined  with  those  of  one 
or  other  of  the  acute  general  diseases  1o 
which  the  acute  leptomeningitis  is  an 
accompaniment  or  sequel.  Those  symp- 
toms which   are  quite  common   in  all 


I  forms  of  acute  leptomeningitis  are  head- 
j  ache,  vertigo,  fever,  nausea,  restlessness, 
I  somnolence,  stupor,  abnormal  changes 
in  the  pulse  and  respiration,  muscular 
spasms,  optic  neuritis,  and  spasms  or 
paralysis  of  the  ocular  muscles.  Almost 
any  of  these  symptoms  may  be  either 
very  marked  features  of'  any  given  cases, 
j  or  very  slight,  or  even  entirely  absent. 
Perhaps  the  most  constant  symptoms  are 
pain  in  the  head,  mental  changes  during 
the  initial  stage,  fever  (although  afebrile 
cases  are  reported);  muscular  twitchings, 
or  spastic  condition  of  the  muscles,  espe- 
cially those  of  the  neck  and  spine;  and 
general  convulsions. 

Pain  in  the  head  is  a  very  frequent 
symptom,  but  if  the  disease  occurs  dur- 
ing the  progress  of  some  grave  general 
disease  it  may  not  be  complained  of. 
i  Irritability,  restlessness,  and  delirium  in 
cases  ushered  in  by  high  fever  are  ex- 
ceedingly common,  and  coma  very  often 
rapidly  supervenes  in  such  cases,  accom- 
panied by  more  or  less  muscular  rigidity 
or  occasional  convulsions.  This  is  par- 
ticularly true  in  infantile  and  other  cases 
of  basilar  meningitis.  The  location  and 
extent  of  the  inflammatory  process  is 
far  more  important  in  determining  the 
symptoms  in  any  given  case  than  is  the 
character  of  the  exudate,  but  the  symp- 
toms are  all  very  largely  influenced  by 
the  etiology  of  the  case.  In  all  cases, 
therefore,  the  previous  history  is  of  the 
utmost  importance  in  order  to  enable  us 
to  attach  due  significance  to  the  symp- 
toms actually  present. 

The  symptoms  of  acute  basilar  lepto- 
meningitis depend  upon  the  amount  and 
distribution  of  the  inflammatory  exu- 
date,  which  may  involve  any  of  the 
cranfal  nerves,  thus  giving  motor,  sen- 
sory, and  special  sense  disturbances, 
deepening  very  often  into  paralysis  of 
I  all    their    functions.     Disturbances  of 


558 


MENINGITIS.    ACUTE  LEPTOMENINGITIS. 


sight,  hearing,  smell,  and  taste  are  com- 
mon. Pain  is  usually  confined  to  the 
head,  face,  and  upper  spinal  regions. 
Ptosis  and  strabismus  are  frequent  symp- 
toms. According  to  Ott,  very  rapid  res- 
piration is  indicative  of  involvement  of 
the  tuber.  There  is  commonly  retrac- 
tion of  the  head,  and  often  more  wide- 
spread spastic  conditions  of  the  mus- 
cles. In  nearly  all  cases  fever  is  present, 
and  may  be  of  a  severe  type,  but  more 
commonly  it  is  of  moderate  grade,  and 
may  be  entirely  absent  in  cases  occurring 
among  emaciated  children  in  poor  sur- 
roundings. When  hydrocephalus  occurs 
as  a  result  of  the  inflammation,  the  spas- 
tic muscular  condition  is  succeeded  by 
more  or  less  general  paralysis,  due  to  the 
increased  intracranial  pressure,  which 
may  directly  or  indirectly  affect  the  mo- 
tor areas.  A  fairly-common  symptom 
preceding  death  is  Cheyne-Stokes  res- 
piration, which  may,  however,  appear 
quite  early  in  the  disease,  and  be  present 
continuously  or  intermittently  until  the 
termination  of  the  case.  It  is  also  com- 
mon in  other  varieties  of  meningitis. 

The  symptoms  of  acute  cortical  menin- 
gitis are  more  markedly  motor  in  char- 
acter than  in  basilar  meningitis,  and 
cranial  nerve-disturbances  and  palsies  are 
not  present,  unless  the  base  is  also  af- 
fected. It  must  be  remembered  that 
quite  frequently  cortical  and  basilar  men- 
ingitis are  associated.  The  chief  distinct- 
ive features  of  cortical  leptomeningitis 
are  due  to  involvement,  by  pressure  or 
irritation,  of  the  motor  areas  underlying 
the  portion  of  the  membranes  affected. 
Thus,  we  may  have  localized  spasms  of 
the  arm  or  face  and  tongue;  motor 
aphasia  either  partial  or  complete;  con- 
vulsions, which  may  be  Jacksonian  or 
general  in  type;  an  1  varying  forms  of 
paralysis,  according  as  more  or  less  of 
the  motor  zone  is  involved.    Optic  neu- 


j  ritis  is  not  so  common  as  in  basilar  men- 
ingitis.  In  the  early  stage  of  the  disease 

I  active  delirium  is  often  present  in  severe 
cases,  giving  way  quickly,  however,  to 

;  apathy,  stupor,  and  coma  as  the  disease 
progresses  and  the  exudate  increases  in 
amount.  The  foregoing  statement  of  the 
symptoms  observed  in  cases  of  acute  lep- 
tomeningitis applies  to  all  cases  of  the 
disease,  except  that,  according  to  the  spe- 
cial pathological  or  etiological  variety  of 
the  disease,  they  are  divided  into  many 
clinical  groups;  all  of  which,  however, 
partake  of  the  same  general  character- 
istics. The  symptoms  of  the  chief  clin- 
ical varieties  met  with  will  now  be  briefly 
given. 

Simple  Acute  Leptomexixgiti  s 
(Cerebral). — This  form  of  acute  lepto- 
meningitis occurs  in  infancy  and  early 
childhood.  Prodromic  symptoms  are 
few  or  entirely  wanting.  The  patient 
may  exhibit  some  restlessness  or  irrita- 
bility for  some  days  before  the  disease 
actually  begins.  The  onset  is  usually 
sudden,  with  fever,  vomiting,  headache, 
delirium,  and  often  early  and  repeated 
convulsions.  The  fever  is  commonly  de- 
cided and  ranges  from  102°  F.  to  105° 
F.  during  the  first  few  days.  In  very 
violent  cases  coma  comes  on  early  and 
often  with  very  few  previous  symptoms, 
and  is  attended  by  rigidity  of  the  cervical 
muscles,  and  also  frequently  of  one  or  all 
of  the  limbs.  The  pulse  is  rapid  at  first, 
but  usually  becomes  slower  after  some 
days,  and  is  again  more  accelerated  later, 
when  it  is  apt  to  be  intermittent.  The 
pulse  in  these  cases  is  subject  to  the 
greatest  variations,  and  may  be  either 
abnormally  slow  or  fast,  but  it  almost  al- 
ways is  deficient  in  tension.  There  is 
usually  hyperesthesia  of  the  sight  and 
hearing.  The  pupils  are  contracted  at 
first, or  irregular  in  size,  and  as  the  disease 
progresses  both  may  be  equally  dilated. 


MENINGITIS.    ACUTE  LEPTOMENINGITIS.  559 


The  muscular  soreness  in  these  eases  is 
often  extreme,  the  slightest  pressure  any- 
where over  the  body  causing  acute  pain. 
Finally  all  of  the  senses  are  obtunded  and 
a  condition  of  complete  coma  with  per- 
sistent muscular  rigidity  results.  This 
rigidity  may  affect  only  the  cervical  mus- 
cles, but  more  commonly  it  is  more  wide- 
spread, and  affects  the  limbs.  The  tache 
cerebrale  is  present.  As  death  approaches, 
muscular  paralysis  is  more  pronounced, 
the  patient  has  spells  of  collapse,  Cheyne- 
Stokes  respiration  often  is  present,  the 
sphincters  relax,  and  death  occurs  in 
from  a  few  days  to  a  few  weeks  from  the 
beginning  of  the  illness.  In  those  cases 
which  recover  the  invasion  is  commonly 
less  abrupt,  the  fever  of  lower  type,  and 
all  of  the  symptoms  less  severe.  It  is 
probable  that  some  of  the  cases,  which 
from  lack  of  information  we  must  clas- 
sify as  cases  of  simple  leptomeningitis, 
really  owe  their  origin  to  infection  which 
cannot  be  traced.  The  number  of  cases 
of  purely  simple  character  is  small  com- 
pared with  the  larger  class  in  which  di- 
rect or  indirect  infection  is  the  causative 
agent. 

The  same  symptomatology  practically 
applies  to  all  of  the  acute  infantile  cases, 
although  the  cases  differ  much  in  sever- 
ity and  duration. 

Acute  Tubercular  Leptomeningi- 
tis.— This  form  of  the  disease  is  clinic- 
ally the  most  important  since  it  is  that 
most  commonly  met  with. 

The  clinical  history  of  tubercular,  or 
basilar,  meningitis,  as  it  is  more  com- 
monly called,  differs  in  some  particulars 
from  the  class  of  cases  above  described, 
but  these  differences  are  by  no  means 
sufficient  to  enable  us  to  always  posi- 
tively  differentiate  them.  The  pro- 
dromal  signs  of  the  disease  are  usually 
much  more  prolonged  than  in  cases  of 
simple  leptomeningitis.    For  a  week  or 


two  the  patient  is  noticed  to  be  unwell. 
The  symptoms  during  this  period  vary 
a  great  deal,  but  include  restlessness, 
peevishness,  mental  apathy  or  irritabil- 
ity, and  disturbed  sleep,  transient  head- 
ache, coated  tongue  and  impaired  appe- 
tite, and  occasional  vomiting,  and  a 
decidedly  pale  or  cachectic  color  of  the 
skin.  Rarely  these  symptoms  are  not 
observed  and  the  onset  may  be  acute. 
Soon  fever  makes  its  appearance  and 
rises  progressively,  with  morning  remis- 
sions, ranging  from  99°  to  about  101 1/2° 
F.,  although  the  evening  temperature 
may  be  much  higher  early  in  the  course 
of  the  disease.  Succeeding  this  pro- 
dromal period  more  decided  and  charac- 
teristic signs  slowly  develop.  These  are 
irregularity  of  the  pulse,  which  has  al- 
ready been  accelerated  in  correspondence 
to  the  degree  of  the  fever  present;  irreg- 
ularity of  respiration,  with  retraction  of 
the  abdomen;  dilatation  of  one  or  both 
pupils,  with  slow  lateral  movement  of  the 
eyes;  and  heightened  fever  at  night,  with 
local  flushings  of  the  face.  Following 
these  or  accompanying  them  are  slight 
or  decided  facial  twitchings  or  a  general 
convulsive  seizure.  Some  form  of  pa- 
ralysis soon  develops.  This  may  be  pto- 
sis, strabismus,  amaurosis,  facial  paraly- 
sis, or  hemiparesis,  or  hemiplegia.  The 
temperature  still  ascends,  opisthotonos 
is  marked,  the  abdomen  is  greatly  re- 
tracted, and  Cheyne-Stokes  respiration 
often  precedes  death,  which  commonly 
occurs  within  four  or  five  weeks.  The 
ophthalmoscope  sometimes  reveals  tuber- 
cles of  the  choroid. 

Case  of  a  boy,  17  years  old,  the  victim 
of  acute  miliary  tuberculosis,  "who  was 
affected  with  a  spasmodic  condition  of 
the  right  hand  resembling  athetosis,  and 
who  also  had  left  hemiparesis.  Diagnosis 
made  of  tubereles  in  ilie  externa]  pari  of 
the  thalamus  and  the  posterior  part  of 
the  internal  capsule.    The  autopsy  con- 


560 


MEN  I NGITIS.    ACUTE  LEPTOMENINGITIS. 


firmed  the  diagnosis,  but  also  showed 
tubercles  in  the  upper  right  ascending 
frontal  convolution.  Ewald  (Gaz  Hebd. 
de  Med.  et  de  Chir.,  May  2,  '91). 

Tubercular  meningitis  presents  no 
symptoms  during-  the  onset.  The  only 
sign  is  a  disharmony, — viz.,  an  irregu- 
larity (dissociation)  of  the  respiratory 
movements  of  the  diaphragm  and  the 
thorax,  which  sets  in  during  the  first  days 
of  meningitis.  Simon  ( La  France  Med. 
et  Paris  Med.,  Mar.  29,  ,(J5). 

Tubercular  Cerebro-Spinal  Lepto- 
meningitis. —  Cases  of  tubercular  cere- 
brospinal meningitis  have  been  studied 
by  Hayenn  Moxon,  Mag-nan,  Shaw,  Liou- 
ville,  Eskridge,  Mills,  and  others.  It  is, 
however,  a  comparatively  rare  affection, 
and  when  it  does  occur  it  is  usually  in 
the  course  of  generalized  tuberculosis. 
According  to  Eskridge,  the  tubercular 
deposits  may  occur  first  in  the  spinal 
membranes;  but  more  commonly  the 
cerebral  and  spinal  membranes  are  af- 
fected together.  In  the  case  studied  by 
Eskridge  and  Mills  and  referred  to  by 
the  latter  in  his  work  on  nervous  dis- 
eases, the  patient  was  16  months  old, 
and  presented  the  following  symptoms: 
"Headache,  lateral  movements  of  the 
head,  temperature  of  103°  F.;  pulse, 
150;  respiration,  84;  and  tetanic  con- 
vulsions, with  some  imposed  clonic  move- 
ments, and  rigidity  of  the  limbs"  (Mills). 
Tli is  case  ran  a  course  of  eight  months. 
The  post-mortem  diagnosis  of  tubercle 
could  not  be  made  macroscopically  in  the 
case,  but  was  established  beyond  question 
by  an  expert  microscopist.  The  symp- 
toms observed  in  such  cases  necessarily 
will  depend  upon  the  mode  of  develop- 
ment, and  upon  the  relation  between  the 
spinal  and  encephalic  tubercular  lesions. 

Epidemic  Cerebro-Spinal  M  eningi- 
tis. — This  form  of  leptomeningitis  is  a 
specific  infectious  disease,  but  presenting 
as  its  chief  pathological  lesion  a  wide- 


spread inflammation  of  the  meninges  of 
the  brain  and  spinal  cord.  It  has  been 
recognized  as  such  for  nearly  one  hun- 
dred years.  Other  names  sometimes  used 
are  "spotted  fever,"  "petechial  fever/" 
and  "malignant  purpuric  fever."'  It  oc- 
curs as  a  sporadic  epidemic  or  endemic 
disease,  and  varies  much  in  malignancy 
in  different  epidemics,  (a)  A  very  malig- 
nant form  is  described  in  which  death 
often  occurs  before  the  exudate  has  time 
to  appear.  The  symptoms  in  this  malig- 
nant variety  are  sudden  onset,  with  chills, 
pain  in  head,  extreme  physical  and  men- 
tal depression,  local  or  general  muscular 
spasms,  fever  of  102°  to  103°  F.;  feeble 
pulse,  becoming  slow;  purpuric  rash  (not 
constant)  and  death  inside  of  twenty- 
four  hours,  or  even  less,  as  in  a  case  re- 
corded by  Stille,  in  which  death  occurred 
within  ten  hours. 

Case  of  leptomeningitis  lasting  only  -i\ 
hours.  First  symptom  was  a  slight  con- 
vulsion, laryngeal  obstruction  simulating 
croup;  high  temperature.  106.5°  F.  to 
107. <>°  F. ;  absence  of  vomiting.  There 
had  been  no  prodromata.  Autopsy 
showed  a  dry,  glazed  brain,  with  adhesion 
between  the  gyri  and  between  the  hemi- 
spheres; the  vessels  of  the  pia  were  in- 
jected. Xo  pus  or  tubercles.  Other 
organs  normal.  Hosmer  (  Boston  .Med. 
and  Surg.  Jour..  May  17.  "88). 

Case  of  meningitis  of  unknown  origin, 
ending  fatally  quite  suddenly,  with 
sharp  elevation  of  temperature  from  nor- 
mal to  105°  F.  in  less  than  two  hours, 
coma,  abolition  of  all  reflexes  and  of  res- 
piration, and  apparent  death,  though  the 
heart  continued  to  beat  and  the  pulse  to 
be  perceptible  for  thirty-eight  hours  after- 
ward, artificial  respiration  being  practiced 
almost  continuously  meanwhile.  Smith 
(Va.  Med.  Mthly..  Oct..  '93). 

(b)  The  ordinary  form  also  begins  sud- 
denly, with  few  premonitory  symptoms, 
I  with  a  chill,  severe  headache,  repeated 
attacks  of  vomiting,  and  moderate  fever. 
Very  early  then'  is  rigidity  of  the  posh  - 


MENINGITIS.    ACUTE  LEPTOMENINGITIS. 


561 


rior  cervical  muscles,  causing  severe  pain. 
There  is  photophobia  and  hypersensitive- 
ness  to  light  and  noise.  Often  there  is 
severe  pain  in  the  limbs  and  back.  Tonic 
and  choreic  spasms  of  the  limbs  occur, 
and,  in  young  children,  general  convul- 
sions are  more  common  than  in  older 
children  or  adults.  Strabismus,  followed 
by  paralysis  of  the  eye-muscles,  with  in- 
volvement of  the  facial  muscles,  fre- 
quently occurs.  During  the  early  stage 
delirium  may  be  a  very  marked  feature, 
but  soon  the  patient  sinks  into  a  stupor- 
ous condition,  but  often  continues  to 
suffer  from  the  severe  head-pains  and 
body-pains  until  the  stupor  becomes 
coma.  The  disease  is  very  irregular  in 
its  course,  remissions  are  frequent  in  all 
its  symptoms,  and  the  fever  especially 
is  apt  to  be  most  variable. 

The  respiration  is  not  apt  to  be  so 
much  disturbed  as  in  tubercular  menin- 
gitis. The  pulse  is  often  extremely  rapid 
in  young  children,  but  in  older  persons 
it  may  be  either  rapid  or  distinctly  slow, 
full,  and  strong  in  the  early  days  of  the 
disease.  The  petechial  rash  occurs  in  a 
considerable  proportion  of  the  cases. 
Stille  noted  its  absence  in  thirty-seven 
out  of  ninety-eight  cases  in  the  Phila- 
delphia Hospital.  Osier  states  that  pete- 
chial and  purpuric  spots  were  commonly 
present  in  his  cases  in  Montreal.  Other 
forms  of  eruptions  noted  as  occurring  in 
this  disease  are  herpes  labialis,  erythema 
nodosum,  ecthyma,  and  pemphigus. 
The  spleen  is  enlarged,  and  constipation 
is  the  rule.  Albuminuria,  glycosuria,  and 
hematuria  Have  been  observed.  The  dis- 
ease runs  a  variable  course  from  a  few 
days  to  several  months.  Of  the  fatal 
cases  a  majority  die  within  the  first  week. 
Recovery  is  often  slow  and  complications 
are  common,  including  pneumonia,  pleu- 
risy, pericarditis,  and  painful  forms  of  ar- 
thritis in  some  epidemics  of  the  disease. 


Attention  called  to  frequency  of  phar- 
yngitis during  epidemics  of  cerebro- 
spinal meningitis.  Sears  (Boston  Med. 
and  Surg.  Jour.,  Aug.  9,  '88). 

Peripheral  or  multiple  neuritis  occurs 
in  some  cases  of  cerebro-spinal  menin- 
gitis. This  coincidence  observed  in  three 
cases.  C.  K.  Mills  (Medical  News,  Mar. 
3,  '88). 

Thirty  cases  of  cerebro-spinal  menin- 
gitis in  an  epidemic.  In  17  cases  the  most 
striking  symptom  was  herpes,  several  of 
these  cases  dying.  In  11  cases  the  urine 
contained  albumin,  but  no  casts;  in  2 
cases  there  was  polyuria,  and  in  1  gly- 
cosuria, the  patient  dying  on  the  fourth 
day.   Friis  (Univ.  Med.  Jour.,  July,  '93). 

Case  of  cerebro-spinal  meningitis  in 
which  persistent  hsematuria  was  present. 
Biggs  (Epitome  of  Med.,  Aug.,  '93). 

Case  of  boy  who  died  of  cerebro-spinal 
meningitis,  which  apparently  originated 
in  trauma.  Remarkable  features  of  the 
case  were  persistent  coma  for  two  weeks 
and  phenomenal  emaciation.  Thompson 
(Med.  Record,  Apr.  8,  '93). 

Eye-symptoms  studied  in  epidemic  of 
cerebro-spinal  meningitis.  Various  affec- 
tions noted  with  more  or  less  frequency 
are  conjunctivitis,  altered  pupils,  pus  in 
the  anterior  chamber,  choroiditis  and 
iritis,  suppurative  cyclitis,  retinitis, 
panophthalmitis,  neuritis,  etc.  The  fun- 
dus should  always  be  examined,  as  there 
is  a  direct  communication  between  the 
arachnoid  space  and  the  deeper  structures 
of  the  eye  through  the  intravaginal  space. 

Of  35  cases,  21  fatal.  Case  of  child, 
aged  20  months,  in  which  there  was 
thrombosis  of  the  central  vein  with  an 
hemorrhagic  retinitis.  The  fundus  was 
normal  in  only  7  cases,  and  1  of  these  7 
had  divergent  strabismus  and  dilated 
pupils,  another  marked  nystagmus,  and 
another  greatly  dilated  pupils.  In  6  cases 
there  was  optic  neuritis,  and  in  19  great 
venous  engorgement  and  tortuosity,  with 
congestion  of  the  optic  disk.  Of  the  3 
cases  in  which  there  was  an  absence  of 
all  eye-symptoms,  2  recovered  and  1  died. 
All  cases  of  strabismus  (8)  were  diver- 
gent, and  the  right  eye  was  always  af- 
fected. Every  extensive  epidemic  is  apt 
to  be  associated  with  a  special  type  of 


562 


MENINGITIS.    ACUTE  LEPTOMENINGITIS.  DIAGNOSIS. 


eye  disease.  Randolph  (Johns  Hopkins 
Hosp.  Bull.,  June,  July,  '92). 

Literature  of  '96-'97-'98. 

Many  of  the  eye-symptoms  of  impor- 
tance in  meningitis  are  largely  motor. 
Thirty-eight  cases  of  meningitis  reported 
— 13  simple  leptomeningitis,  12  cerebro- 
spinal meningitis,  13  tuberculous.  In  8 
of  the  13  cases  of  leptomeningitis  there 
were  no  eye-symptoms.  The  patient  with 
purulent  meningitis,  in  which  no  eye- 
symptoms  were  present,  showed,  post- 
mortem, the  meninges  covered  with  pus 
and  extensive  adhesions  between  the  pia 
and  dura  mater.  In  the  cases  of  cerebro- 
spinal meningitis  eye-symptoms  were  ab- 
sent in  7.  Loss  of  iris-reflex  was  present 
in  1,  dilated  and  fixed  pupils  in  another, 
strabismus  in  a  third,  and  in  the  fourth 
the  pupils  were  dilated,  but  reacted  to 
light. 

No  eye-symptoms  were  present  in  8  of 
those  having  tuberculous  meningitis. 
Cerebro-spinal  meningitis  has  as  promi- 
nent symptoms  paralysis  of  third,  fourth, 
ophthalmic  division  of  fifth,  sixth,  and 
seventh  nerves,  with  nystagmus  and 
ptosis  from  cortical  lesions;  choked  disk, 
optic  neuritis,  perineuritis,  plastic  and 
suppurative  iritis,  conjunctivitis,  oedema 
of  the  lids,  hemianopsia  as  a  cortex  or 
tract  lesion.  In  simple  meningitis  or  lep- 
tomeningitis the  eye-symptoms  are  of 
more  importance  in  determining  the  diag- 
nosis than  in  the  cerebro-spinal  type. 
The  most  reliable  is  optic  neuritis.  A.  E. 
Davis  (Med.  News,  June  5,  '97). 

The  sequelae  include  blindness,  deaf- 
ness, chronic  hydrocephalus,  severe  neu- 
ralgias of  the  head,  and  mental  disease 
of  various  types. 

Syphilis  may  very  rarely  cause  an 
acute  cerebral  leptomeningitis,  but  it  is 
much  more  commonly  a  cause  of  chronic 
leptomeningitis.  The  symptoms  do  not 
differ  from  other  varieties  of  acute  lepto- 
meningitis, excepting  for  their  associa- 
tion with  other  evidences  of  syphilis, 
such  a?  gummata  or  specific  ulcerations 
of  the  bones. 


Literature  of  '96-'97-'98. 

In  acute  syphilitic  meningitis  extreme- 
ly-intense headaches,  repeated  vomiting, 
and  occasional  elevation  of  temperature 
are  the  first  symptoms.  If  the  process 
be  at  the  base,  vertigo,  mental  troubles, 
symptoms  of  compression  of  the  cranial 
nerves,  polyuria,  and  bulbar  phenomena 
supervene,  and  profound  depression  suc- 
ceeds, ending  in  fatal  coma.  If  the  con- 
vexity be  chiefly  affected,  phenomena  of 
excitement  predominate;  noisy  delirium, 
repeated  convulsions  and  hallucinations. 
Coma  comes  on  later — often  with  hemi- 
plegia or  monoplegia.  Specific  treatment 
is  of  no  use  in  these  acute  cases.  Teissier 
and  Roux  (Treatment,  Mar.  10,  '98). 

Traumatic  Leptomeningitis.  —  The 
symptoms  present  in  cases  of  fractures, 
concussion  of  the  brain,  or  perforating 
wounds  of  the  skull  are,  from  the  nature 
of  these  injuries,  often  of  a  mixed  char- 
acter, depending  upon  the  extent  and  se- 
verity of  the  traumatism,  and  whether 
there  is  also  injury  to  the  brain-sub- 
stance. Under  these  circumstances  the 
leptomeningitis  occurs  as  a  complication 
of  the  injury,  and  presents  no  special 
symptoms  other  than  those  already  re- 
ferred to  as  common  in  all  cases  of  the 
disease.  These  will  depend  for  their  in- 
tensity and  grouping  upon  the  position 
and  extent  of  the  inflammation,  and  will 
be  mingled  with  those  of  the  injury 
itself. 

Diagnosis.  —  It  is  necessary  to  distin- 
guish the  various  types  of  acute  lepto- 
meningitis from  each  other,  from  en- 
cephalitis, from  the  meningeal  symptoms 
of  the  continued  fevers,  acute  rheuma- 
tism, pneumonia,  tetanus,  cerebral  tumor 
and  abscess,  unvmia.  the  hvdrocephaloid 
disease  of  Marshall  Hall,  and  hysteria. 

In  meningitis  when  tubercle,  otitis, 
trauma,  syphilis,  and  oilier  well-known 
causes  are  not  present,  the  probability  is 
that  the  micro-organism  of  Hie  epidemic 
variety  is  the  cause,  the  case  being  a. 


MENINGITIS.    ACUTE  LEPTOMENINGITIS.  DIAGNOSIS. 


563 


sporadic  example  of  cerebro-spinal  menin- 
gitis. Idiopathic  cases  are  characterized 
by  the  following  points:  (a)  Both  brain 
and  spinal  cord  are  frequently  attacked, 
and  spinal  symptoms  are  common;  these 
symptoms  are  rare  in  other  varieties  of 
meningitis  which  attack  both  brain  and 
cord.  (6)  The  duration  of  illness  varies 
from  one  to  four  weeks,  the  variation  de- 
pending mainly  on  the  stage  of  the  dis- 
ease at  which  the  cerebral  membranes 
bcome  affected.  (c)  Recoveries  are 
fairly  frequent,  (d)  The  best  treatment 
seems  to  consist  in  the  administration  of 
mercury  and  iodides,  (e)  The  affection 
of  the  cerebral  membranes  may  be  either 
at  the  vertex  or  the  base  or  both,  (f) 
The  cases  occur  perhaps  most  frequently 
in  the  cooler  parts  of  the  year.  There  is 
some  evidence  for  considering  these  cases 
to  be  associated  with  epidemic  meningitis 
and  for  considering  that  the  cause  of  both 
may  be  diplococcus  pneumoniae.  Bot- 
tomley  (Practitioner,  June,  '94). 

Acute  leptomeningitis,  either  purulent 
or  sero-purulent,  is  separated  from  cases 
of  so-called  serous  leptomeningitis  (ex- 
ternal hydrocephalus)  chiefly  by  the 
greater  frequency  of  the  former,  the 
more  prolonged  and  milder  course  usu- 
ally of  the  latter  affection,  and,  as  ad- 
vised by  Quincke,  by  lumbar  puncture. 
If  the  fluid  obtained  has  a  specific 
gravity  of  1009  or  less,  and  contains 
more  than  two  parts  of  albumin  per 
thousand,  Quincke  regards  it  as  hydro- 
cephalic fluid.  Fever  is  slight  or  absent 
in  serous  meningitis  and  choked  disk  is 
more  common  than  in  acute  purulent  or 
suppurative  meningitis  (Mills).  The 
diagnosis  of  the  serous  meningitis  de- 
scribed by  Quincke  from  certain  cases  of 
tubercular  leptomeningitis  is  impossible 
unless  there  is  a  distinctly  tubercular  his- 
tory obtainable. 

Literature  of  '96-'97-'98. 

Lumbar  puncture  is  a  valuable  aid  to 
diagnosis,  and  it  has  a  probable  thera- 
peutic,'  indication   in   serous   and  sero- 


purulent  meningitis,  likewise  in  chlorosis 
with  marked  cerebral  manifestations. 
Bertram  W.  Sippy  (Deut.  med.  Woch., 
June  10,  '97). 

Simple  acute  purulent  leptomeningitis 
of  the  basilar  type  differs  from  tubercular 
basilar  leptomeningitis  by  its  more  abrupt 
invasion,  the  absence  of  signs  or  history 
of  tuberculosis,  and  tendency  to  higher 
range  of  temperature;  while  prodromic 
symptoms,  with  more  irregular  course, 
temperature,  and  pulse,  and  possibly 
choroidal  tubercles,  are  common  in  the 
latter  affection. 

Epidemic  cerebro-spinal  leptomenin- 
gitis is  distinguished  from  the  other 
varieties  by  the  presence,  in  the  vicinity, 
of  other  cases  of  the  disease;  its  very 
sudden  onset  with  severe  rigors  and 
marked  pains  in  back  and  limbs;  its 
spinal  symptoms,  the  presence  of  its  skin 
eruptions,  and  by  the  alarming  intensity 
of  all  the  cerebral  and  spinal  symptoms, 
and  the  rapidity  with  which  they  attain 
their  maximum.  The  sporadic  cases  of 
the  same  disease  run  a  less  acute  course, 
are  of  extremely  rare  occurrence,  and  are 
much  more  liable  to  be  confounded  with 
one  of  the  continued  fevers  presenting 
grave  nervous  symptoms. 

Literature  of  '96-'97-'98. 

Results  of  the  bacteriological  examina- 
tion of  fluid  obtained  by  lumbar  punct- 
ure in  four  cases  of  epidemic  meningitis. 
In  all  the  cases  the  meningococcus  intra- 
cellularis  of  Weichselbaum  was  found  in 
the  fluid.  The  fluid  obtained  by  puncture 
was  centrifugated,  and  from  the  sediment 
cover-glass  preparations  were  made  in 
the  usual  way  and  stained  according  to 
Loefner.  In  all  the  preparations  numer- 
ous leucocytes  were  found,  in  which  were 
often  seen  three  or  four  pairs  of  cocci. 
The  diplococci  were  very  like  gonococci 
in  appearance,  and  lance-shaped  diplo- 
cocci were  not  found.  Pure  cultures  of 
the  meningococcus  were  obtained  upon 
glycerin  agar-agar  in  each  ease. 


564 


MENINGITIS.    ACUTE  LEPTOMENINGITIS.  DIAGNOSIS. 


By  this  method  a  diagnosis  can  be 
easily  made  in  epidemic  meningitis  by 
lumbar  puncture,  and  a  differential  diag- 
nosis during  life  between  it  and  tubercu- 
lar meningitis.  W.  Holdheim  (Deutsche 
med.  Woeh.,  No.  34,  '96). 

In  cases  of  meningitis  of  doubtful  diag- 
nosis lumbar  puncture  is  of  great  im- 
portance. The  operation  consists  in  with- 
drawing cerebro-spinal  fluid  from  the 
lowest  part  of  the  vertebral  canal  by 
means  of  a  puncture  carried  through  the 
ligaments  connecting  the  lumbar  verte- 
brae. A  hollow  needle  with  trocar  and 
cannula,  or  an  hypodermic  needle  may  be 
used:  but  it  is  better  not  to  aspirate. 
Following  method  recommended:  The 
child  is  placed  upon  its  right  side,  with 
the  thighs  so  bent  that  it  lies  curled  up, 
with  the  vertebral  column  well  bowed. 
In  those  suffering  from  cerebral  irrita- 
tion, in  the  restless,  and  in  those  who  are 
not  yet  unconscious,  it  is  necessary  to 
give  an  anaesthetic.  The  exact  position 
of  the  patient  is  unimportant,  so  long  as 
the  vertebral  column  is  kept  convex  at 
the  seat  of  puncture  from  the  time  the 
needle  is  inserted  until  it  is  withdrawn. 

The  skin  over  the  lower  part  of  the 
back  is  well  washed  with  soap  and  water, 
dried,  and  sponged  with  a  solution  of  cor- 
rosive sublimate  ( 1  in  2000) ,  while  the  tro- 
car and  cannula  of  the  smallest  hydrocele 
size  is  sterilized  by  boiling  in  a  test-tube 
for  three  minutes.  To  find  the  most  suit- 
able point  for  puncture  a  perpendicular  is 
dropped  upon  the  bed  from  the  highest 
point  of  the  crest  of  the  ilium  (the  pa- 
tient being  on  the  side),  for  this  line 
crosses  the  upper  border  of  the  spine  of 
the  fourth  lumbar  vertebra,  and  thus 
marks  the  position  for  puncture.  The 
trocar  and  cannula  are  plunged  through 
the  skin  immediately  to  one  side  of  the 
spine  of  the  third  lumbar  vertebrae,  and 
on  a  level  with  its  lower  border.  It  is 
pushed  on  boldly  until  the  point  of  the 
trocar  touches  bone — the  lower  border  of 
the  lamina.  The  handle  of  the  trocar  is 
then  directed  upward,  so  that  its  point 
passes  downward  over  the  lamina.  II  is 
then  pushed  onward  until  a  grating  sen- 
sation is  felt. 

It  is  important  to  see  that  the  end  of 
the  cannula  is  well  beveled  and  (its  closely  ! 


to  the  neck  of  the  trocar.  The  trocar  is 
withdrawn  as  soon  as  it  is  felt  that  it  has 
fairly  entered  the  subarachnoid  space, 
care  being  taken  that  the  cannula  is  not 
at  the  same  time  pulled  out  of  the  verte- 
bral canal.  D'Arcy  Power  (Clin.  Jour., 
May  20,  '96). 

In  lumbar  puncture  as  a  means  of 
diagnosis  in  epidemic  cerebro-spinal  men- 
ingitis a  small  trocar  of  some  strength 
should  be  used,  and  should  be  inserted 
downward  and  inward  at  a  point  slightly 
lower  than  the  lowest  point  of  the  spi- 
nous process  of  the  second  lumbar  verte- 
bra, and  one  inch  outside.  It  should 
penetrate  to  a  depth  of  rather  more  than 
two  inches.  These  measurements  are  for 
adults.  The  pus  is  often  thick  and  flows 
with  difficulty.  Williams  (Boston  Med. 
and  Surg.  Jour.,  Sept.,  '97). 

Following  conclusions  reached,  regard- 
ing the  value  of  lumbar  puncture:  1. 
Tapping,  as  a  diagnostic  or  therapeutic 
adjunct,  is  quite  worthless,  according  to 
personal  experiments,  but  other  investi- 
gators have  discovered  in  the  cerebro- 
spinal fluid  proof  positive  of  the  tubercle 
bacillus.  2.  In  acute  cases  of  meningitis 
cerebro-spinalis  the  cerebral  fluid  does 
not  contain  morbid  products  which,  if 
applied  to  animals,  may  serve  to  verify 
clinical  observation.  3.  When  the  acute 
stage  has  been  passed  and  hydrocephalus 
is  present,  no  diagnostic  assistance  can  be 
obtained  from  the  examination  of  the 
fluid.  4.  As  a  therapeutic  agent  is  equally 
inefficacious  in  meningitis  cerebro-spinalis 
and  meningitis  tuberculosa,  but  indi- 
vidual cases  do  improve  when  operated 
on  early,  often  repeated,  and  large  quan- 
tities abstracted.  Monti  (Med.  Press  and 
Circ,  Dec.  1,  '97). 

Case  of  cerebro-spinal  meningitis  in 
which  the  diagnosis  was  confirmed  by 
finding  the  diplococcus  of  Weiehselhaum 
in  the  meninges  at  the  necropsy.  James 
B.  Herrick  (Jour.  Amer.  Med.  Assoc., 
July  2.  '98). 

Following  conclusions  reached  from 
study  of  epidemic  of  cerebro-spinal  menin- 
gitis: 1.  There  is  no  constant  and  defi- 
nite relation  between  the  severity  of  the 
symptoms  and  the  degree  of  turbidity  of 
the  spinal  fluid.  2.  There  is  little  or  no 
connection  between  the  number  of  organ- 


MENINGITIS.    ACUTE  LEPTOMENINGITIS.  DIAGNOSIS. 


565 


isms  and  the  number  of  cells  present  in 
the  spinal  fluid.  3.  In  many  cases  there 
appears  to  be  but  slight  connection  be- 
tween the  number  of  organisms  found  in 
the  spinal  fluid  and  the  severity  of  the 
disease.  4.  Unless  the  subsequent  exami- 
nation of  the  spinal  fluid  is  carefully  per- 
formed no  deductions  as  to  the  presence 
or  absence  of  meningitis  are  justifiable. 
A.  H.  Wentworth  (Lancet,  Oct.  1,  '98). 

Attention  called  to  sign  given  by  Ker- 
nig  for  diagnosis  of  meningitis:  person- 
ally found  in  41  out  of  46  cases. 

The  patient  is  examined  first  in  the 
dorsal  decubitus  and  then  sitting.  In 
the  first  position  it  is  very  easy  for  the 
patient  to  extend  the  leg  completely; 
in  the  sitting  posture,  however,  the  leg 
can  no  longer  be  extended  completely.  In 
very  marked  cases  it  cannot  be  extended 
beyond  90  degrees,  and  in  all  cases  not 
beyond  135  or  140  degrees.  But  as  soon 
as  the  patient  lies  down,  complete  exten- 
sion is  again  easy.  This  phenomenon  has 
not  been  met  with  outside  of  meningitis. 
Netter  (Le  Bull.  Med.,  July  24,  '98). 

The  diagnosis  of  leptomeningitis  of 
the  vertex  from  the  basilar  form  is  made 
by  the  great  prominence  of  motor  in- 
volvement, and  the  active  delirium  and 
abnormal  cerebration  in  the  early  days  of 
the  disease  in  cases  of  the  former;  with 
absence  of  the  symptoms  of  cranial- 
nerve  irritation  or  paralysis.  As  re- 
marked by  Osier  in  his  "Practice  of  Med- 
icine," the  signs  of  cortical  leptomenin- 
gitis cannot  be  separated  clinically  from 
the  symptoms  present  at  times  in  pneu- 
monia and  other  general  diseases,  and 
due  to  simple  congestion  of  the  pia 
mater,  unless  there  is  also  present  some 
positive  sign  of  leptomeningitis  due  to 
coincident  or  subsequent  involvement  of 
the  cranial  nerves  by  extension  of  the  in- 
flammation to  the  base  of  the  brain. 

The  diagnosis  between  acute  lepto- 
meningitis, typhoid  fever,  or  any  of  the 
acute  specific  fevers  is  made  by  a  careful 
review  of  the  history  of  the  illness,  the 
presence  or  absence  of  the  eruptions  of 


the  various  fevers,  and  by  the  presence  of 
cranial-nerve  spasm  or  palsy,  optic  neu- 
ritis, or  of  monoplegia  or  hemiplegia  in 
cases  of  leptomeningitis. 

From  brain-tumor  the  diagnosis  of 
subacute  cases  of  leptomeningitis  may  be 
exceedingly  difficult.  The  two  condi- 
tions may  co-exist,  and  the  same  may  be 
said  of  cerebral  abscess,  which  is  not  in- 
frequently associated  with  purulent  lep- 
tomeningitis, or  finally  all  three  condi- 
tions may  be  present  in  the  same  case,  as 
in  a  case  seen  by  the  writer  in  which 
several  calcareous  growths  between  the 
dura  and  arachnoid  pressed  deeply  down 
through  the  post-parietal  region  to  the 
lateral  ventricle,  into  which  an  abscess, 
formed  about  the  tumor,  finally  dis- 
charged. The  autopsy  showed  an  ex- 
tensive cortical  purulent  leptomeningitis 
over  the  vertex,  and  its  development  with 
rupture  of  the  abscess  at  the  lateral  ven- 
tricle was  the  immediate  cause  of  death. 
Usually,  however,  in  cases  of  brain- 
tumor,  its  symptoms  are  more  regularly 
progressive,  the  pain  more  definitely 
localized,  and  the  pressure-symptoms 
more  clearly  denned  than  is  the  case  in 
leptomeningitis,  while  there  is  rarely 
such  variations  of  pulse  and  temperature 
as  are  commonly  present  in  the  latter 
affection,  and  optic  neuritis  is  more  com- 
mon in  brain-tumor. 

Certain  cases  of  uremia  may  resemble 
some  types  of  leptomeningitis.  Here  the 
careful  and  repeated  examination  of  the 
urine,  the  presence  of  some  form  of 
oedema  or  dropsy,  the  possible  presence 
of  albuminuric  retinitis,  and  a  careful 
study  of  the  previous  history  of  the  case 
will  suffice  to  establish  the  diagnosis. 
Much  more  frequently  uraemia  has  a 
clinical  resemblance  to  brain-tumor. 

Literature  of  '96-'97-'9S. 

Four  cases  in  which  the  differential 
diagnosis  between  uraemia  and  meningitis 


566 


MENINGITIS.    ACUTE  LEPTOMENINGITIS.  DIAGNOSIS. 


was  extremely  difficult.  First  patient 
had  paralysis  of  the  muscles  of  the  left 
eye  and  complete  right  hemiplegia,  ex- 
cepting the  upper  branch  of  the  facial. 
At  autopsy  there  was  some  oedema  of 
the  brain,  but  no  lesions  and  a  diffuse 
pyelonephritis.  Second  case  presented 
paralysis  of  the  muscles  of  the  left  eye 
and  the  lowTer  branch  of  the  right  facial. 
There  were  hyaline  and  granular  casts 
and  considerable  albumin  in  the  urine. 
No  cerebral  lesion  was  found.  Third 
case  had  no  nervous  symptoms  excepting 
coma.  The  urine  was  heavily  loaded 
with  albumin;  nevertheless  the  kidneys 
were  negative,  but  a  profuse  purulent  in- 
filtration was  found  over  the  base  and 
convexity  of  the  brain.  Fourth  case  pre- 
sented the  symptoms  of  delirium  tremens. 
The  urine  was  albuminous.  Suddenly 
focal  palsies  occurred  in  both  eyes,  but 
at  the  autopsy  only  the  kidneys  were 
diseased.  A.  R.  Edwards  (Amer.  Jour. 
Med.  Sci.,  Aug.,  '90). 

Tubercular  leptomeningitis  may  be 
confounded  with  the  hydrocephaloid 
disease  first  described  by  Marshall  Hall. 
This  disease  occurs  in  young  children  as 
a  result  of  disease  or  of  extremely  bad 
conditions  of  life.  It  is  characterized  by 
intense  cerebral  ansemia,  and  the  child 
passes  through  a  cycle  of  symptoms 
closely  analogous  to  adynamic  cases  of 
leptomeningitis.  It  often  follows  chronic 
diarrhoea.  It  is  distinguished  from  the 
inflammatory  conditions  by  absence  of 
marked  fever,  of  rigidity  of  the  neck- 
muscles,  and  of  any  cranial-nerve  or  cor- 
tical palsies;  while  under  treatment  by 
stimulants,  suitable  food,  hygiene,  and 
tonics,  the  condition  is  often  readily 
curable. 

Differential  diagnosis  between  syphilitc 
and  tubercular  meningitis:  The  latter  is 
rare  under  1  year  of  age:  the  former 
may  occur  very  soon  after  birth.  In  the 
tubercular  form  paralysis  seldom  opens 
the  scene,  while  it  is  often  an  initial 
symptom  in  the  specific  form.  In  the 
latter  form  there  is  often  apyrexia  instead 
of  fever;   the  opposite  condition  prevails 


in  tubercular  meningitis.  In  specific  cases 
the  cry  is  rather  plaintive,  and  differs 
from  the  true  hydrocephalic  cry.  The 
pulse  is  often  irregular,  but  the  typical 
slow  pulse  of  tubercular  disease  is  not 
observed.  Respiration  in  the  specific 
cases  is  not  so  often  affected  with  irregu- 
larity, and  is  very  rarely  of  the  Cheyne- 
Stokes  type.  The  retraction  of  abdomen, 
vomiting,  constipation,  delirium,  con- 
tractures, peculiar  posture,  rapid  wast- 
ing, and  the  munching  belong  more  prop- 
erly to  the  tubercular  cases.  Stoeber 
(L'Union  Med.  du  Canada,  Aug.,  '91). 

Literature  of  '96-'97-'98. 

Distinct  form  of  meningitis  recognized, 
occurring  almost  exclusively  in  infants. 
Description  of  this  disease  is  based  upon 
eleven  cases,  all  of  which  occurred  in  pre- 
viously-healthy infants  under  a  year  old. 

The  onset  is  gradual  in  some,  sudden 
in  others;  but,  in  all,  the  most  constant 
and  characteristic  symptoms  are  severe 
vomiting,  extreme  head-retraction,  and 
stupor,  passing  into  coma,  of  remarkably 
long  duration,  generally  several  weeks, — 
the  excessive  head-retraction  persi-t in- 
to the  last. 

The  cases  reported  all  terminated 
fatally,  none  in  less  than  five  weeks, 
while  some  children  lived  for  three 
months  or  even  longer.  At  the  autopsies 
inflammation  of  the  pia  and  arachnoid 
was  found  over  a  very  definite  area  at 
the  basis  of  the  brain,  hydrocephalus  in 
all  the  cases,  and,  in  some,  closure  of  the 
openings  between  the  fourth  ventricle 
and  the  subarachnoid  space.  In  no  in- 
stance was  any  sign  of  tubercular  dis- 
ease discovered,  either  in  the  cranial 
cavity  or  elsewhere.  J.  W.  Carr  i  Med. 
Week.,  Apr.  16,  '97). 

Tubercular  leptomeningitis  and  ty- 
phoid fever  may  present  very  similar 
clinical  appearances.  The  former,  how- 
ever, lias  retracted  abdomen,  constipa- 
tion, normal  or  only  slight  splenic  en- 
largement, local  or  general  spasms  or  pa- 
ralysis, a  generally  lower  temperature, 
j  more  frequent  irre</ularitj/  in  the  pulse, 
I  respiration,  and  temperature,  and  the  ab- 


MENINGITIS.    ACUTE  LEPTOMENINGITIS.  ETIOLOGY. 


567 


sence  of  any  pathognomonic  eruption,  to 
distinguish  it:  besides  the  history  of  the 
case  which  may  aid  materially  in  form- 
ing an  early  diagnosis,  in  cases  in  which 
no  visible  signs  of  other  tubercular  le- 
sions are  observed. 

In  typhoid  the  knee-jerks  are  altered; 
but  the  alteration  is  constant.  They  are 
always  exaggerated,  and  ankle-clonus 
may  be  present.  In  tubercular  meningitis 
the  jerk  is  either  absent  or  unequal  on 
the  two  sides,  or  present  on  one  side  and 
absent  on  the  other.  Angel  Money  (Aus- 
tralian Med.  Gaz.,  June  15,  '94). 

Tubercle  bacilli  found  in  removed 
cerebro- spinal  fluid  in  twenty-seven  out 
of  thirty-seven  cases,  proving  presence  of 
tuberculous  meningitis,  afterward  veri- 
fied. Furbringer  (Berliner  klin.  Woch., 
No.  13,  '95). 

Literature  of  '96-'97-'98. 

Thirty-two  cases  with  sixty  lumbar 
punctures.  There  was  no  unpleasant 
after-effect,  and  this  was  chiefly  to  be  as- 
cribed to  the  fact  that  the  puncture  was 
practised  with  the  patient  on  his  side, 
and  that  only  one  case  of  cerebral  tumor 
was  thus  treated.  There  were  3  cases  of 
epidemic  meningitis,  2  of  which  were 
fatal.  There  were  seven  cases  of  tuber- 
culous meningitis  all  fatal.  Lumbar 
puncture  was  here  often  of  diagnostic 
value.  Only  twice  was  the  tubercle  bacil- 
lus found,  but  the  fluid  presented  in  gen- 
eral characteristic  appearances.  It  was 
clear  or  only  slightly  opalescent,  con- 
tained an  increased  amount  of  albumin, 
and  was  more  or  less  rich  in  cells.  In  4 
cases  the  diagnosis  of  serous  meningitis 
(Quincke)  was  made.  The  nature  of  a 
case  of  haemorrhagic  pachymeningitis 
was  made  certain  by  this  procedure.  In 
the  remaining  cases,  lumbar  puncture 
did  not  assist  the  diagnosis,  and  it  had 
no  clear  therapeutic  effect.  These  cases 
included  apoplexy,  cerebral  tumor, 
uraemia,  cerebral  syphilis,  etc.  Spinal 
puncture  is  a  valuable  extension  of  our 
means  of  diagnosis,  and  some  therapeutic 
value  is  probable  in  cases  of  serous  and 
sero-purulent  meningitis,  as  well  as  in 
the   cerebral  disturbances  of  chlorosis. 


Thiele  (Brit.  Med.  Jour.,  from  Deut.  med. 
Woch.,  June  10,  '97). 

Diagnosis  of  tubercular  meningitis  by 
lumbar  puncture  studied  diligently  in 
Heubner's  clinic  in  Charite  for  the  space 
of  a  year.  Nineteen  cases  being  observed. 
The  bacillus  was  found  in  every  instance. 
Negative  results  reported  by  others  must 
necessarily  have  been  due  to  imperfect 
technique.  In  three  instances  where  the 
microscope  did  not  reveal  the  bacillus 
positive  results  obtained  by  inoculation. 
Method  was  that  of  Quincke,  whose  ap- 
paratus for  puncture  was  made  use  of. 
The  operation  is  entirely  harmless. 
Slawyk  (Berliner  klin.  Woch.,  May  2, 
'98). 

Emphasis  laid  on  the  Skeer  sign,  which, 
when  present,  will  enable  a  diagnosis  of 
tuberculous  meningitis  to  be  made  very 
early.  It  is  dependent  on  the  deposition 
of  tubercles  around  the  pupillary  mar- 
gin of  the  iris,  showing  itself  first  as  a 
distinct  wreath  of  white  clouds  about  a 
millimetre  from  the  margin.  This  sign 
occurs  before  any  change  has  taken  place 
in  the  size  of  the  pupillary  orifice.  After 
three  or  four  days  these  minute  cloud- 
like masses  disappear,  and  a  yellowish- 
brown  circle  takes  their  place,  becoming 
more  and  more  attenuated  as  the  pupil 
dilates.  D.  B.  Brower  (Brit.  Med.  Jour., 
July  9,  '98). 

Etiology.  —  Acute  leptomeningitis 
arises  from,  and  is  associated  with,  very 
many  pathological  conditions.  In  a  cer- 
tain proportion  of  cases  the  causal  factor 
is  entirely  obscure  and  no  local  or  gen- 
eral source  of  infection  can  be  found. 
Usually,  however,  the  disease  is  due  to 
infection  of  the  membranes  with  pathog- 
enic micro-organisms,  and  very  often 
the  source  is  apparent  or  can  be  easily 
inferred. 

The  chief  causes  giving  rise  at  times 
to  acute  leptomeningitis  may  be  enu- 
merated as  follows: — 

1.  Tuberculosis. 

2.  The  specific  poison  of  the  epidemic 
cerebro-spinal  meningitis. 


508 


MENINGITIS.    ACUTE  LEPTOMENINGITIS.  ETIOLOGY. 


3.  Suppurative  aural  or  nasal  disease, 
caries  of  the  cranial  bones. 

4.  The  diarrhceal  and  dysenteric  dis- 
eases of  infancy  and  childhood. 

5.  The  acute  general  diseases,  —  in- 
cluding pneumonia,  erysipelas,  influenza, 
scarlet  fever,  ulcerative  endocarditis, 
diphtheria,  pertussis,  rheumatic  fever, 
septicaemia,  pyaemia,  and  possibly  ty- 
phoid fever. 

6.  Traumatism,  surgical  operations, 
and  sun-stroke. 

7.  The  syphilitic,  gouty,  and  rheu- 
matic diatheses. 

8.  Sclerosis  of  the  blood-vessels,  mil- 
iary aneurism,  embolism,  intracranial 
tumor  and  abscess,  and  nephritis  at  times 
influence  its  development;  and,  in  chil- 
dren especially,  marasmus  and  poor  con- 
ditions of  life  powerfully  predispose 
toward  some  grade  of  leptomeningitis. 

The  above-mentioned  conditions  are 
all  at  times  either  predisposing  or  excit- 
ing causes  of  acute  inflammation  of  the 
arachnopia.  A  large  majority  of  the 
cases  of  basilar  meningitis  in  infants  and 
children  is  due  to  tuberculosis.  Most  of 
the  cases  arising  from  necrosis  or  sup- 
puration about  the  head  arise  from 
necrosis  of  the  petrous  portion  of  the 
temporal  bone  and  middle-ear  suppura- 
tion. Cases  also  arise  by  infection  from 
the  nose;  the  infection  gaining  access  to 
the  ear  by  way  of  the  Eustachian  tube, 
and  thence  to  the  pia  by  way  of  the 
blood-vessels  or  lymphatics. 

Of  thirty-two  cases  of  tubercular  basi- 
lar meningitis  twenty-four  were  second- 
ary to  chronic  disease  of  the  lungs,  which 
was  clinically  recognizable.  No  case  re- 
covered. Herman  Rieder  (Miinch.  med. 
Woch.,  Dec.  3,  '89). 

Tubercular  meningitis  in  children,  is, 
in  all  probability,  always  secondary  in 
its  cerebral  development  to  a  primary 
focus  elsewhere,  and  not  idiopathic. 
Simon  (Revue  Men.  des  Mai.  de  l'Enfance, 
June,  '03). 


Epidemic,  observed  at  Asheville,  North 
Carolina,  prevailed  from  January  to  the 
end  of  March,  producing  one  hundred  and 
twenty-five  cases.  Not  one  of  the  ninety- 
nine  cases  of  which  notes  were  taken  lived 
on  high,  Avell-drained  ground.  Nearly 
all  of  the  cases  occurred  in  families  using 
well-water.  In  68  per  cent,  of  cases  the 
sanitary  condition  of  the  dwelling  was 
bad,  in  22  per  cent,  fair,  in  only  10  per 
cent.  good.  Meriwether  (N.  C.  Med. 
Jour.,  July,  '88). 

Cerebro-spinal  meningitis  is  practically 
an  autoinfection  from  the  micrococcus 
lanceolatus,  which,  ordinarily  innocuous 
and  normally  present  in  the  mouth,  is 
rendered  virulent  by  extraneous  causes 
which  chemically  alter  the  bodily  secre- 
tions. Flexner  and  Barker  (Johns  Hop- 
kins Hosp.  Bull.,  June,  July,  '93). 

In  60  to  70  per  cent,  of  recorded  cases 
of  cerebro-spinal  meningitis  Frankel's 
diplococcus  lanceolatus  found.  Out  of 
ten  cases,  two  in  which  there  was  defi- 
nite pus-formation,  diplococci  present  in 
enormous  numbers;  in  those  in  which 
only  fibrinous  exudation  existed  micro- 
organisms scantier  and  found  inside  the 
nucleus  of  the  cells.  The  "diplococcus  in- 
tracellularis"  the  true  cause  of  epidemic 
cerebro-spinal  meningitis.  Jaeger  (Zeit. 
f.  Hyg.  u.  Infects.,  B.  19.  H.  2,  '95). 

Seven  cases  of  pseudomeningitis,  six 
fatal,  without  anatomical  lesions,  follow- 
ing an  epidemic  of  influenza.  Krannhals 
(Deut.  Archiv  f.  klin.  Med.,  Dec.  20,  '94). 

Epidemic  of  cerebro-spinal  meningitis 
which  affected  children  only.  There  were 
forty-three  cases  in  a  total  population  of 
about  two  hundred  and  fifty  people. 
Origin  of  the  epidemic  was  traced  to  the 
village-school,  where  it  was  learned  that 
a  few  weeks  previously  a  number  of  the 
children  had  been  affected  with  a  sharp 
diarrhoea.  The  same  children  affected 
with  meningitis  had  been  victims  of  the 
preceding  diarrhoea.  Disinfection  and 
closing  of  the  school  temporarily  caused 
a  cessation  of  the  epidemic.  Monk  (Brit. 
Med.  Jour.,  July  30,  '92). 

Literature  of  '96-'97-'98. 

Bacteriological  examination  of  the 
meningeal  exudate  in  a  case  of  cerebro- 
spinal meningitis  showing,  in  the  pus- 


MENINGITIS.    ACUTE  LEPTOMENINGITIS.  ETIOLOGY. 


569 


cells,  a  special  diplococcus  distinguished 
from  that  of  Frlinkel  by  a  globular  form 
and  a  frequent  disposition  in  fours,  by  its 
not  staining  by  Gram's  method,  and  by 
the  difficulty  of  causing  infection  in  ani- 
mals when  subcutaneously  inoculated. 
Kischevski  (La  Med.  Mod.,  Jan.  8,  '96). 

Although  the  organisms  are  much 
alike,  the  meningococci  vary  more  in  size 
among  themselves  than  the  gonococci. 
The  arrangement  in  the  cells  is  much 
alike  in  both  cases.  Both  decolorize  by 
Gram's  method.  The  meningococci,  how- 
ever, grow  rapidly  in  glycerin  agar:  a 
fact  of  great  value  in  the  diagnosis  of 
cerebro-spinal  meningitis  by  the  aid  of 
spinal  puncture.  It  was  impossible  to 
inoculate  guinea-pigs  and  rabbits,  but, 
while  carrying  on  the  observations,  the 
operator  had  rhinitis,  with  marked  de- 
pression, headache,  nervousness,  and  a 
drawing  pain  in  the  neck.  The  pus  from 
the  nose  showed  cocci  similar  to  those  in 
the  cultures  and  these  soon  overcame  the 
other  bacteria  of  the  nose,  appearing  &T- 
most  in  pure  culture.  F.  Kiefer  (Berliner 
klin.  Woch.,  No.  28,  '96). 

Case  of  rapid  death  after  labor  from  in- 
fectious meningitis  from  the  pneumo- 
coccus.  Crouzat  (Rev.  Obstet.  Internat., 
Apr.  21,  '97). 

Case  of  epidemic  cerebro-spinal  menin- 
gitis in  a  girl,  aged  2 1/2  years,  termi- 
nating in  recovery  at  the  end  of  thirty- 
four  days.  Lumbar  puncture  was  made 
and  the  cerebro-spinal  fluid  gave  a  pure 
culture  of  the  intracellular  meningo- 
coccus (Weichselbaum-Jaeger),  which, 
according  to  the  researches  of  Heubner, 
should  be  considered  the  specific  cause 
of  epidemic  cerebro-spinal  meningitis. 
Stoelzner  (Berliner  klin.  Woch.,  No.  16, 
'97). 

The  pneumococcus  and  meningococcus 
are  the  chief  producers  of  cerebro-spinal 
meningitis,  and  other  micro-organisms, 
especially  the  pyogenic  cocci,  play  the 
causative  part  in  only  a  few  cases.  In 
circumscribed  meningitis  the  pneumococ- 
cus has,  up  to  the  present,  alone  been 
found.  A  general  infection  by  way  of  the 
blood  must  be  distinguished  from  a  local 
infection  arising  from  some  region  in  the 
neighborhood  of  the  skull.  One  of  the 
most  frequent  modes  of  infection  is  the 
micro-organisms'  gaining  access  from  the 


naso-pharynx  through  the  Eustachian 
tube  into  the  middle  ear,  and  thence  into 
the  cranial  cavity.  Wolf  (Berliner  klin. 
Woch.,  Mar.  8,  '97). 

Epidemic  cerebro-spinal  meningitis  is 
to  be  classed  among  the  contagious  dis- 
eases, belonging  to  the  same  category  as 
phthisis  pulmonalis.  Unsanitary  condi- 
tions exert  great  influence  in  affording 
a  proper  nidus  for  the  growth  of  the 
germs  of  this  disease.  William  J.  Class 
(Med.  News,  Dec.  3,  '98). 

One  hundred  and  eleven  cases  of  epi- 
demic cerebro-spinal  meningitis  exam- 
ined. Conclusions  are  as  follow:  Epi- 
demic cerebro-spinal  meningitis  is  an 
acute  infectious  disease  produced  by  a 
micrococcus  characterized  by  its  growth 
in  pairs  and  by  certain  cultural  and  stain- 
ing properties.  The  seat  of  the  disease  is 
the  meninges  of  the  cord  and  brain.  It  is 
possible  that  the  nose  is  the  portal  of 
entry.  There  is  an  acute  purulent  in- 
flammation in  the  pia-arachnoid.  The 
cortex  is  affected  by  extension.  The  cord 
is  always  affected.  The  organisms  are 
found  in  considerable  numbers  in  the  ma- 
jority of  acute  cases.  The  surest  method 
of  diagnosis  is  by  spinal  puncture.  In 
the  early  stage  a  fluid  more  or  less 
clouded  by  pus-cells,  containing  the  or- 
ganisms can  be  found. 

There  are  no  prodromata;  there  is 
vomiting  and  pain  in  the  head.  In  most 
cases  there  is  pain,  stiffness,  and  muscu- 
lar contraction  of  the  neck.  There  is 
usually  delirium,  and  in  many  cases  un- 
consciousness passing  into  coma.  Pa- 
ralyses are  common.  Councilman,  Mal- 
lory,  and  Wright  (Report  State  Board 
of  Health  of  Mass.,  '98). 

The  disease  of  infancy,  recently  de- 
scribed as  simple  or  non-tuberculous  pos- 
terior basic  meningitis,  is  a  specific  dis- 
ease, due  always  and  only  to  a  particular 
micro-organism.  The  micro-organism 
which  is  the  cause  of  this  disease  is  a 
diplococcus  almost  identical  with  the  dip- 
lococcus described  by  Weichselbaum  and 
Jaeger;  it  presents,  however,  some  slight 
differences,  which  are  probably  to  be  ac- 
counted for  by  natural  variation. 

The  simple  posterior  basic  meningitis 
of  infants  must,  on  bacteriological  evi- 
dence, be  considered  as  a  sporadic  form 
of  the  disease  known  as  epidemic  cerebro- 


570 


MENINGITIS.    ACUTE  LEPTOMENINGITIS.  PATHOLOGY. 


spinal  meningitis,  the  D.  intracellular^ 
having  been  shown  by  recent  observers 
to  be  the  cause  of  some,  at  least,  of  the 
epidemics  of  that  disease.  The  periar- 
thritis, which  occasionally  complicates 
posterior  basic  meningitis  of  infants,  is 
due  to  the  same  diplococcus  that  is  found 
in  the  meningeal  exudation.  G.  F.  Still 
(Jour,  of  Path,  and  Bact.,  volume  v,  p. 
147,  '98). 

Case  of  boy  of  13,  who  for  several  days 
presented  all  the  clinical  signs  and  symp- 
toms of  tuberculous  meningitis.  The  boy 
then  passed  seven  worms  and  all  the 
symptoms  disappeared  instantly. 

Another  case  of  a  boy  of  7,  who  also 
presented  all  the  symptoms  of  tubercu- 
lous meningitis.  An  emetic  was  given, 
then  calomel  and  santonin,  which  brought 
out  several  worms.  Nevertheless  the  con- 
dition of  the  child  continued  to  grow 
worse,  the  meningitis  took  its  regular 
course,  and  the  child  died.  Duchesne 
(Jour,  de  Med.  et  de  Chir.  Prat.,  24,  VI, 
'98). 

Pathology. — The  post-mortem  appear- 
ances in  cases  of  acute  leptomeningitis 
differ  according  to  the  stage  of  the  in- 
flammation at  which  the  patient  dies, 
and  the  character  of  the  exudate  espe- 
cially is  influenced  by  the  duration  of  the 
disease.  In  some  of  the  very  malignant 
cases  of  cerebro-spinal  meningitis  in- 
tense hypergemia  of  the  membranes  may 
be  alone  observed  by  the  naked  eye, 
death  having  occurred  before  the  exu- 
date had  time  to  form.  In  the  majority 
of  cases,  however,  very  marked  lesions 
are  found,  with  copious  exudate  of  serum 
or  pus,  and  accompanied  by  more  or  less 
acute  hydrocephalus,  especially  in  tuber- 
cular cases,  with  some  degree  of  ventricle 
dilatation.  Quite  frequently  the  epen- 
dyma  is  found  involved,  and,  less  fre- 
quently, the  brain-substance  subjacent  to 
the  affected  area  is  also  the  seat  of  in- 
flammatory and  degenerative  changes, 
due  to  direct  extension  of  the  inflamma- 
tory process,  and  to  the  pressure  exerted 


upon  it  by  the  meningeal  exudate.  The 
exudate  found  in  these  cases  varies  very 
much  in  color  and  consistency,  from 
an  almost  colorless  serous  exudate  to 
whitish-grayish  or  greenish,  gelatinous 
pus.  In  cases  dying  before  exudation 
can  occur,  the  pia-arachnoid  often  pre- 
sents large  areas  of  brilliant-red  hyper- 
I  aamia.  This  condition  may  involve  the 
entire  cortex,  or  be  unilateral,  or  may  be 
chiefly  at  the  base,  with  scattered  patches 
elsewhere  over  the  surface  of  the  men- 
inges. In  such  cases  the  patient  un- 
doubtedly succumbs  to  an  intense  gen- 
eral toxaemia,  rather  than  to  any  in- 
fluence produced  by  the  local  lesions 
within  the  cranial  cavity.  The  ventricles 
are  most  frequently  dilated  in  the  tuber- 
cular cases,  although  in  many  other  types 
of  the  disease  this  lesion  is  also  found. 
When  the  disease  is  chiefly  cortical  or 
over  the  convexit}^  of  the  brain,  it  is  most 
commonly  most  intense  over  the  fissure 
of  Sylvius  and  over  the  motor  convolu- 
tions. In  some  cases  numerous  opacities 
of  the  pia  are  present,  scattered  through- 
out the  base  and  lateral  regions  of  the 
brain,  and  less  frequently  over  the  cor- 
tex. About  these  may  be  collection-  of 
turbid  yellowish  serum,  shreds  of  lymph, 
or  various  types  of  pus.  In  cases  of  long 
standing  the  pus  may  undergo  caseation, 
with  partial  absorption  of  its  fluid,  and 
leave  a  yellowish,  caseous  mass  upon  the 
thickened  and  degenerated  membranes. 
At  the  base  all  of  these  appearances  may 
include  or  cover  the  sheaths  of  the 
cranial  nerves,  and  often  the  nerves 
themselves  are  found  softened  and 
broken  down.  Some  writers  have  laid 
stress  upon  a  purely-serous  variety  of 
acute  leptomeningitis  in  which  there  is, 
in  addition  to  large  ventricle,  effusion 
or  exudate  of  serum  between  the  dura 
and  tin1  arachnopia.  contained  in  a  thin 
pseudomembranous  new  formation.  Eef- 


MENINGITIS.    ACUTE  LEPTOMENINGITIS.  PATHOLOGY. 


571 


erence  to  this  condition  will  be  found 
under  the  remarks  upon  Acute  Hydro- 
cephalus. Cases  of  purely-serous  lepto- 
meningitis running  an  acute  course  are 
extremely  rare. 

The  great  majority  of  cases  show  some 
degree  of  purulent  exudate,  sometimes 
admixed  with  coloring  matter  from  the 
blood  in  severe  cases  of  the  epidemic 
cerebro-spinal  form.  Sinus-thrombosis 
is  quite  frequently  found  in  cases  arising 
from  aural  disease,  sometimes  associated 
with  abscess. 

In  tubercular  leptomeningitis  of  the 
basal  membranes  in  infancy  and  child- 
hood the  exudate  is  frequently  thick  and 
gelatinous,  while  the  pearly-grayish  tu- 
bercles can  usually  be  seen  by  the  naked 
eye  along  the  course  of  the  vessels,  and 
scattered  throughout  the  membrane. 
The  deposit  of  tubercle  at  the  base  com- 
monly occurs  over  the  position  of  the 
optic,  olfactory,  and  third  nerves  and  the 
crura  cerebri.  It  may  include  any  of  the 
cranial  nerves.  In  adults  miliary  tuber- 
cles are  frequent  over  the  cortical  areas, 
while  in  children  the  cortex  is  only  rarely 
involved.  Tuberculosis  of  other  organs 
in  the  body  is  usually  found. 

In  cortex  cerebri  in  tubercular  menin- 
gitis, as  shown  by  the  fresh  method  of 
examination,  are  found  just  under  the 
meninges,  very  small  round  cells  and  also 
numerous  flask-shaped  cells  which  give 
off  many  fine  processes,  forming  a  mesh- 
work  with  neighboring  cells.  These  cell- 
processes  cannot  be  traced  deeper  than 
the  third  layer  of  cortical  cells.  The 
minute  vessels  are  dilated.  In  many 
specimens  the  nerve-cells  of  the  second 
and  third  layers  are  stunted  and  atro- 
phied, often  only  the  nucleus  being  left. 
As  these  degenerated  nerve-cells  are  al- 
ways in  close  contact  with  the  spindle- 
cells,  which  are  probably  to  be  looked 
upon  as  scavenger-cells,  it  appears  that 
the  degenerate  nerve-cells  ;ue  taken  up 
by  them.  Goodall  (Brain,  Summer  and 
Autumn,  '91). 


Literature  of  '96-'97-'98. 

Peculiar  type  described  characterized 
by  lack  of  caseation  in  the  tubercles. 
Tendency  to  cicatrization  of  newly- 
formed  granulation-tissue.  The  pia  be- 
comes indurated,  giving  a  pathological 
condition  more  frequently  seen  in  syphi- 
lis than  in  tuberculosis  of  the  meninges. 
The  affection  seems  to  run  a  chronic  and 
an  insidious  course.  Busse  (Medicine. 
Nov.,  '96). 

The  post-mortem  appearances  of  epi- 
demic cerebro-spinal  meningitis  of  ordi- 
nary type  are  those  of  wide-spread  acute 
hyperemia,  inflammation,  and  exudation, 
involving  the  meninges  of  the  brain  and 
spinal  cord.  The  brain  is  engorged  with 
blood,  the  veins  are  distended,  and  the 
membranes  hyperaemic  and  inflamed. 
The  spinal  cord  is  in  the  same  condition. 
The  exude  is  sero-purulent  or  purulent, 
and  grayish  or  yellowish  in  color.  Some- 
times it  is  abundant  over  the  upper  por- 
tions of  the  hemispheres.  The  pus  often 
extends  down  to  the  extremity  of  the 
spinal  cord  (being  more  abundant  in 
patches  usually),  and  the  whole  cord  may 
be  evenly  surrounded  by  pus.  There  are 
patches  of  thickening,  and  adhesions  are 
found  between  the  pia  and  the  cortex  in 
cases  of  some  weeks'  duration.  The  ven- 
tricular fluid  is  increased,  but  not  to  the 
extent  common  in  tubercular  leptomen- 
ingitis. Rarely,  areas  of  capillary  haem- 
orrhage and  encephalitis,  with  softening, 
are  found  in  the  cerebral  substance,  and 
an  abscess  may  be  associated.  The  spleen 
is  usually  enlarged.  Among  the  com- 
plications recorded  by  various  writers  are 
pneumonia,  pleurisy,  pericarditis,  endo- 
carditis, and  acute  nephritis. 

The  microscopical  appearances  of  epi- 
demic cerebro-spinal  leptomeningitis  in- 
clude minute  capillary  haemorrhages  in 
the  pia  of  the  brain  and  cord,  distended 
vessels  with  masses  of  leucocytes  swelling 
their  sheaths,  granule-Cells  and  red  and 


572 


MENINGITIS. 


ACUTE  LEPTOMENINGITIS. 


PATHOLOGY. 


white  blood-corpuscles  infiltrating  the 
cortical  layer  of  brain  and  cord,  and  de- 
generative changes  in  the  cells  of  the 
spinal  and  cerebral  nerves,  especially  in 
the  posterior  spinal  nerve-roots. 

The  infecting  micro-organisms  of  lep- 
tomeningitis are  the  streptococcus  pyog- 
enes, the  bacillus  communis  coli,  the 
intracellular  diplococcus  of  Weichsel- 
baum,  the  staphylococcus  pyogenes  au- 
reus, the  tubercle  bacillus,  and  the  micro- 
coccus lanceolatus  or  pneumococcus. 
The  pneumococcus  is  now  generally  re- 
garded as  most  closely  associated  with 
epidemic  cerebro-spinal  meningitis.  Ac- 
cording to  Putnam,  the  symptoms  of  lep- 
tomeningitis are  partly  due  to  the  ab- 
sorption of  toxic  ptomaines  formed  by 
the  micro-organisms,  the  other  factors 
being  the  pressure  of  the  exudate  itself, 
and  the  direct  pathogenic  micro-organ- 
isms upon  the  meninges  of  the  brain. 

Literature  of  '96-'97-'98. 

Case  of  child,  6  weeks  old,  previously 
healthy,  with  the  exception  of  a  cough 
for  a  few  days  preceding.  Upon  auscul- 
tation crepitant  rales  were  audible,  fairly 
uniformly  distributed.  Diagnosis  of 
acute  bronchitis  was  made.  A  few  days 
later  the  child  was  seized  with  violent 
convulsions  and  vomiting,  passing  into  a 
semicomatose  condition,  and  died.  Puru- 
lent meningitis  most  marked  on  the 
vertex.  No  tubercles  were  present,  the 
lungs  were  free  from  pneumonia,  except 
for  two  small  areas  of  congestion  at  the 
right  base.  The  meningeal  fluid  con- 
tained abundant  pneumococci.  Ferrand 
(La  Med.  Mod.,  July  8,  '9G). 

The  meningococcus  behaves  differently 
for  different  observers  upon  the  ordinary 
culture-media,  although  in  general  it  can 
be  said  to  lose  its  vitality  quite  readily. 
It  is  not  at  all  certain  that  the  organism 
is  really  not  a  variety  of  the  pneumonia. 
The  pathological  anatomy  of  the  disease 
includes  more  or  less  bronchitis  and  hy- 
peremia of  the  lungs,  with  occasional 
areas  of  pneumococcic  infiltration  ;  ecchy- 


moses  in  the  endocardium  and  pericar- 
dium, with  slight  alteration  of  the  heart- 
muscle;  a  small  spleen,  often  with  a 
wrinkled  capsule.  The  liver  is  hyper- 
semic  and  darker  in  color.  The  urine 
often  contains  albumin  and  casts;  and 
the  kidneys  are  intensely  hypersemic  and 
there  is  parenchymatous  degeneration  of 
the  cortex.  Sometimes  swelling  of  the 
solitary  follicles  of  the  intestine  and  of 
Peyer's  patches  has  been  observed. 
Mayer  (Munch,  med.  Woch.,  Aug.  30, 
'98). 

Prognosis. — The  prognosis  of  all  forms 
of  acute  leptomeningitis  is  very  grave. 
That  of  the  simple  purulent  and  sero- 
purulent  types,  whether  in  infants  or 
adults,  is  grave,  but  should  always  be 
guarded,  owing  to  the  many  difficulties 
in  the  way  of  a  positive  diagnosis.  The 
outlook  in  the  tubercular  form  of  the 
disease  is  wholly  bad,  notwithstanding 
the  fact  that  a  few  cases  have  been  re- 
ported in  which  complete  recovery  is 
stated  to  have  occurred. 

Case  of  tubercular  meningitis  in  which 
the  diagnosis  was  established  beyond  a 
doubt,  followed  by  recovery.  Furbringer 
(Deut.  med.  Woch.,  No.  3G,  "94). 

Literature  of  ^dl-'dS. 

With  the  very  rarest  exceptions,  an 
attack  of  tubercular  meningitis  termi- 
nates in  death.  In  other  forms  of  menin- 
gitis death  often  occurs,  but  recovery  is 
more  frequent  than,  in  the  tubercular 
form.  D'Arcy  Power  (Clinical  Jour., 
May  20,  '96). 

Two  cases  of  meningitis,  apparently 
tuberculous  in  nature,  with  recovery. 
George  N.  Acker  (Medical  News,  May  29, 
'97). 

Cases  of  localized  or  unilateral  lepto- 
meningitis in  which  it  is  possible  to  re- 
move the  cause  by  surgical  operation 
offer  hope  of  recovery.  This  applies 
chiefly  to  traumatic  cases,  and  to  some 
of  the  cases  arising  from  suppurative 
aural  inflammation.    The  syphilitic  type 


MENINGITIS.    ACUTE  LEPTOMENINGITIS.  TREATMENT. 


573 


usually  yields  to  prompt  and  energetic 
treatment. 

In  cerebro-spinal  leptomeningitis, 
whether  of  sporadic  or  epidemic  variety, 
the  prognosis,  while  very  grave,  always 
admits  of  hope  that  the  disease  may 
prove  abortive  and  recovery  take  place. 
A  fair  percentage  of  such  cases  recover 
from  apparently  hopeless  conditions,  and 
while  the  recovery  may  be,  at  times,  very 
rapid  and  satisfactory,  more  often  it  is 
slow  and  protracted.  In  cases  in  which 
the  exudate  is  serous,  absorption  may 
take  place,  and  if  the  effusion  has  not 
been  excessive  in  amount  the  brain  may 
recover  from  the  effects  of  the  increased 
intercranial  tension,  and  the  consequent 
dilatation  of  its  ventricles.  The  mor- 
tality of  the  epidemic  cerebro-spinal 
from  is  greatest  during  the  first  half  of 
the  period  of  the  epidemic,  many  more 
recoveries  being  recorded  in  the  later 
weeks  of  its  prevalence.  Malignant  cases 
of  this  disease  die  sometimes  within  a 
few  hours  after  being  stricken  with  the 
early  disease. 

Literature  of  '96-'97-'98. 

A  pneumococcic  meningitis  is  rarely- 
recovered  from,  the  fatal  result  occurring 
in  a  few  days.  In  epidemic  cerebro-spi- 
nal meningitis,  on  the  other  hand,  only 
one-third  to  one-half  of  the  cases  die. 
The  recognition  of  this  form  of  menin- 
gitis by  the  help  of  spinal  puncture  is  of 
considerable  importance.  Heubner  (Deut. 
med.  Woch.,  July  2,  '96). 

During  the  winter  and  spring  of  1897 
an  epidemic  of  cerebro-spinal  meningitis 
occurred  in  Massachusetts;  47  cases  were 
treated  in  the  Boston  City  Hospital.  The 
mortality  in  these  47  cases  was  72  per 
cent.  Lumbar  puncture  was  performed 
in  a  large  proportion  of  these  cases,  and 
in  most  of  them  the  diplococcus  intra- 
cellularis  meningitidis  of  Weichselbaum 
was  found  in  the  cloudy  serum  of  pus 
obtained.  Editorial  (Boston  Med.  and 
Surg.  Jour.,  Dec.  30,  '97). 

It  is  impossible  to  say  how  long  an 


epidemic  of  cerebro-spinal  meningitis 
will  last  or  what  the  termination  will  be 
in  a  given  case  until  the  lapse  of  a  con- 
siderable interval  of  time  during  which 
the  patient  is  free  from  symptoms.  In 
chronic  cases  the  mortality  is  estimated 
to  be  fully  as  high  as  in  the  acute 
variety.  The  mortality  varies  very  much 
in  different  epidemics.  Hirsch  estimates 
it  at  from  20  to  70  per  cent.  A.  H.  Went- 
worth  (Lancet,  Oct.  1,  '98). 

In  all  cases  of  leptomeningitis  the 
early  occurrence  of  stupor,  coma,  or  se- 
vere convulsions  are  bad  omens;  and 
high  fever  during  the  first  weeks  is 
always  an  unfavorable  sign.  In  many 
cases  of  acute  leptomeningitis,  especially 
when  the  disease  occurs  in  infants  or 
young  children,  remissions  in  the  severe 
symptoms  are  common  from  about  the 
fourth  to  the  tenth  day,  but  too  often  the 
improvement  is  but  temporary.  When 
this  marked  remission  occurs,  it  is  prob- 
ably due  to  the  fact  that  in  children  the 
primary  shock  to  the  brain  is  greater 
than  in  adults,  and,  as  the  brain  becomes 
accustomed  to  the  increased  pressure  due 
to  congestion  and  exudate,  its  functions 
are  reasserted  for  the  interval  of  the  re- 
mission, only  to  be  overcome  again  as  the 
disease  progresses  and  the  effusion  in- 
creases. Recovery  from  acute  leptomen- 
ingitis is  only  rarely  perfect,  for  usually 
some  permanent  defect  remains  as  a 
sequel.  These  sequelae  may  be  mental, 
sensory,  or  motor  in  character,  depend- 
ing upon  the  location,  severity,  and  ex- 
tent of  the  inflammation. 

Treatment.  —  The  treatment  of  acute 
leptomeningitis  will  depend  greatly  upon 
its  cause,  but  aside  from  those  cases 
originating  in  diathetic  states  of  the  body 
(such  as  the  rheumatic,  gouty,  or  syph- 
ilitic), or  those  of  traumatic  or  septic 
origin  in  which  surgical  measures  may 
be  advisable,  the  generally-accepted 
treatment  of  all  cases  is  mainly  symptom- 


574 


MENINGITIS.    ACUTE  LEPTOMENINGITIS.  TREATMENT. 


atic.  The  cases  due  to  the  general 
diatheses  above  referred  to  should,  of 
course,  receive  appropriate  treatment  to 
counteract  them,  in  addition  to  the  other 
measures  necessary  to  combat  the  inflam- 
mation. 

Case  of  chronic  tubercular  basilar 
meningitis  in  an  adult  in  which  the  diag- 
nosis was  established  and  cure  effected 
by  means  01  injections  of  tuberculin. 
Dennison  (Jour.  Amer.  Med.  Assoc.,  June 
3,  '93). 

Literature  of  '96-'97-'98. 

Instance  of  use  of  tuberculin  in  a  case 
of  tuberculous  meningitis.  The  injection 
of  a  very  minute  dose  after  complete 
coma  had  persisted  for  twenty  hours  was 
followed  by  spontaneous  movements, 
ability  to  speak,  and  recovery  of  con- 
sciousness. On  the  next  day  the  paralytic 
phenomena,  the  deviation  of  tongue  and 
face,  the  pupillary  inequality,  and  ptosis 
disappeared.  The  continence  of  the 
sphincters  was  regained  to  the  extent 
that  an  enema  was  retained  for  an  hour 
and  then  expelled  with  faeces,  and  that 
there  were  three  voluntary  urinations. 
On  the  following  day  the  patient  seemed 
to  be  cured;  but  later  in  the  same  day 
fever  reappeared,  with  pain  and  swelling 
in  the  left  buttock,  and  the  patient  died 
upon  the  following  morning.  M.  E.  Mou- 
range  (Gaz.  Hebdom.  de  Med.  et  de  Chir., 
No.  '89,  '96). 

Persons  afflicted  with  epidemic  cerebro- 
spinal meningitis  should,  whenever  pos- 
sible, be  isolated,  and  all  evacuations 
should  be  rendered  sterile  by  the  use  of 
antisepsis.  William  J.  Class  (Medical 
News,  Dec.  3,  '98). 

All  varieties  of  acute  leptomeningitis 
demand  a  quiet,  well  ventilated  and  dark- 
ened room,  and  an  intelligent,  capable 
nurse.  The  patient  should  be  put  into 
conditions  of  the  most  perfect  mental 
and  physical  rest  obtainable  in  the  case. 
All  noise,  brighi  light,  and  unnecessary 
conversation  should  be  excluded.  The 
food  should  be  nourishing,  easily  digesti- 
ble, and  given  at  regular  intervals,  for 


special  attention  must  be  paid  to  the 
stomach  in  all  of  these  cases,  since  vom- 
iting is  so  frequently  a  decided  symptom 
of  the  disease.  The  chief  indications 
during  the  first  week  are  to  relieve  pain 
and  procure  rest  and  sleep;  to  lessen  the 
amount  of  blood  within  the  skull:  and, 
in  some  cases,  to  reduce  the  general  bod- 
ily temperature. 

Literature  of  '96-'97-'98. 

In  epidemic  cerebro-spinal  meningitis 
there  is  no  known  remedy  which  either 
checks  the  disease  or  shortens  its  course. 
Some  relief  from  nervous  symptoms  is 
obtained  by  the  use  of  sedatives  and  anal- 
gesics. Complications  must  be  treated 
as  they  arise.  The  emaciation,  weakness, 
and  anaemia  demand  appropriate  hy- 
gienic, dietetic,  and  tonic  treatment. 
Value  of  lumbar  puncture  is  purely  diag- 
nostic. A.  H.  Wentworth  (Lancet,  Oct. 
1,  '98). 

Two  cases  apparently  of  cerebro-spinal 
meningitis,  one  in  a  boy  with  high  fever, 
frontal  and  occipital  headache,  and  re- 
traction of  the  head;  and  the  other  in  a 
man  who  became  comatose  in  the  first 
day  of  observation.  Both  were  given 
large  doses  of  ergot,  and  recovered.  A 
third  patient  with  herpes  and  beginning 
strabismus  died  under  the  same  treat- 
ment. E.  G.  Cutler  (Boston  Med.  and 
Surg.  Jour.,  Nov.  24,  "98). 

For  the  relief  of  pain  morphine,  hyp- 
odermically,  is,  perhaps,  the  best  means. 
It  should  be  given  in  doses  large  enough 
to  produce  the  required  effect.  Chloral 
and  the  bromides  are  valuable  adjuvants, 
and  they  also  do  good  in  allaying  motor 
spasm,  and  the  excessive  irritability  of 
the  nerve-centres.  In  very  young  chil- 
dren and  in  the  aged,  chloral  should  be 
used  with  some  caution,  owing  to  its  ac- 
tion upon  the  heart.  The  cephalic  and 
spinal  ice-bags  are  also  valuable  in  re- 
lieving pain,  and  at  the  same  time  limit 
the  fever.  When  the  patient's  hair  is 
I  abundant  the  scalp  should  be  shaved. 


MENINGITIS.    ACUTE  LEPTOMENINGITIS.  TREATMENT. 


575 


When  the  asthenic  stage  is  reached,  they 
should  be  used  with  caution,  for  they 
may  depress  very  young  children  to  the 
point  of  collapse. 

For  the  purpose  of  lessening  the  intra- 
cranial congestion  and  limiting  the  in- 
flammation as  far  as  possible,  bleeding 
has  been  practiced,  but  is  only  proper  in 
young,  strong,  and  otherwise  healthy 
adults.  It  should  never  be  employed  in 
children  or  the  aged.  Dry  cupping  is 
valuable  and  does  not  exhaust  the  vital- 
ity of  the  patient.  They  may  be  applied 
to  the  back  of  the  neck,  temples,  or  be- 
hind the  ears,  and  even  in  cases  where 
general  blood-letting  is  not  contra-indi- 
cated they  are  extremely  useful  in  reliev- 
ing pain  and  allaying  restlessness. 
Leeches  are  employed  at  times. 

In  chronic  haemorrhagic  leptomenin- 
gitis, blisters  and  galvanism  to  the  head 
(1  to  5  milliamperes)  recommended. 
Lombroso  (Centralb.  fur  Nerv.  Psychi.  u. 
gericht.  Psychop.,  Apr.,  '92). 

Literature  of  '96-'97-'98. 

Treatment  of  case  of  tubercular  menin- 
gitis which  recovered  consisted  in  ice- 
bags  to  the  shaved  head,  poultices  over 
tlie  whole  body  up  to  the  neck,  leeches 
to  the  septum  of  the  nose,  and  potassium 
iodide,  internally,  in  doses  of  at  first  2 
drachms  daily.  The  drug  was  borne 
without  serious  effects.  Janssen  (Deut. 
med.  Woch.,  No.  11,  p.  169,  '96). 

When  insomnia  is  persistent  sulphonal 
or  trional  may  be  used;  or  a  combination 
of  morphine,  chloral,  and  bromide  of  po- 
tassium, which  also  helps  to  control 
muscular  spasms.  Hydrobromate  of  hy- 
oscine  is  recommended  by  J.  M.  Da 
Costa  for  the  control  of  muscular  spasm. 
For  the  severe  muscular  pains  of  the 
epidemic  cerebro-spinal  disease  Eoland 
0.  Curtin  advises  phenacetin  as  the 
safest  and  most  efficient  of  the  anti- 
pyretics. Weakness  is  a  contra-indica- 
tion  to  its  use.     Mustard  plasters  or 


liniments  may  also  be  employed  for  the 
same  purpose. 

Result  of  hot  baths  in  cerebro-spinal 
meningitis.  Case  of  man,  of  tuberculous 
aspect,  who  suffered  from  severe  cerebro- 
spinal meningitis.  Hot  bath  was  given 
and  was  followed  by  a  slight  amelioration 
of  the  general  condition,  improvement  be- 
coming more  marked  after  each  succes- 
sive bath,  until,  by  the  time  the  eighth 
had  been  given,  recovery  was  about  com- 
plete. In  a  second  case  condition  of  pa- 
tient was  even  more  serious,  owing  to 
cardiac  asthenia,  and  the  result  was 
equally  satisfactory.  Baths  were  given 
daily  at  a  temperature  of  104°  F.  and 
ten  minutes'  duration.  Vorochilsky 
(Russkaia  Med.,  No.  4,  '95). 

Literature  of  '96-'97-'98. 

In  cerebro-spinal  meningitis  value  of 
hot  packs  emphasized.  The  hot  cloths 
are  applied  for  three-fourths  to  one  hour. 
The  rigidity  of  the  neck  and  hyperses- 
thesia  particularly  diminish  under  this 
treatment.  Schlesinger  (Munch,  med. 
Woch.,  Oct.  27,  '96). 

Five  cases  of  cerebro-spinal  meningitis 
successfully  treated  by  hot  baths.  The 
temperature  of  the  daily  bath  varied 
from  99.5°  to  104°  F.  M.  Jewnin  (Ther. 
Monats.,  H.  11,  S.  581,  '96). 

Seven  cases  of  cerebro-spinal  menin- 
gitis treated  by  hot  baths,  of  which  5 
completely  recovered. 

Of  the  deaths,  one  was  a  foudroyant 
case,  which  died  within  forty-eight  hours; 
the  others  were  in  the  late  stage  of  the 
disease,  the  baths  being  employed  only 
during  the  first  two  weeks. 

The  method  is  as  follows:  The  patient 
is  placed  in  the  bath  at  the  temperature 
of  90.5°  to  92.75°  F.,  and  hot  water 
gradually  added  until  104°  F.  is  reached. 
While  in  the  bath  an  ice-bag  or  a  Leiter 
cold-water  coil  is  placed  upon  the  head. 

If  there  is  great  tenderness  of  the  back, 
the  sheet  may  be  used  to  move  the  pa- 
tient. The  bath  must  be  previously 
cushioned  and  thorough  after-drying 
omitted.  The  patient  is  placed  upon  a 
dry  sheet,  laid  upon  a  woolen  quilt,  and 
covered  by  the  same,  over  which  a  light 
cover  is  placed;   he  remains  in  this  posi- 


576  MENINGITIS.    ACUTE  LEPTOMENINGITIS.  TREATMENT. 


tion  for  one  hour  before  removal.  The 
time  of  the  bath  is  immaterial — early 
morning  or  late  evening.  Nourishing 
food,  even  meat,  should  be  given;  even 
diarrhoea,  should  this  occur,  does  not 
contra- indicate  it.  Wine,  brandy  (in 
milk),  and  also  beer,  are  given.  Alfred 
Wolisch  (Ther.  Monats.,  H.  5,  '96). 

When  the  pyrexia  needs  to  be  con- 
trolled, the  spinal  ice-bag,  in  addition  to 
the  ice-cap,  is  valuable,  and  may  be  sup- 
plemented by  cool  sponging.  If  more 
decided  measures  are  needed  small  doses 
of  antipyrine  or  acetanilid  answer  the 
purpose.  Aconite  and  veratrum  viride 
are  used  at  times  in  the  first  days  of  the 
disease,  for  the  purpose  of  quieting  the 
circulation. 

Eemedies  given  to  directly  influence 
the  inflammation  are  mercury  and  the 
iodides.  The  former  may  be  given  pref- 
erably in  the  form  of  calomel,  in  small 
doses  frequently  administered  upon  the 
tongue,  as  early  in  the  disease  as  possible. 
The  iodides  are  of  more  service  during 
the  later  stages  to  cause  absorption  of 
the  exudate.  Both  are  valuable  reme- 
dies, and  have  received  the  indorsement 
of  the  highest  authorities.  They  may  be 
combined  with  other  remedies,  for  it  is 
desirable  to  disturb  the  patient  as  little 
as  possible. 

Those  cases  arising  during  the  course 
of  acute  bowel  disorders  in  infancy  de- 
mand the  removal  of  the  poisonous  mat- 
ter contained  in  the  bowels  as  an  initial 
step  in  the  treatment,  and  for  this  pur- 
pose irrigation  of  the  bowels  should  be 
employed. 

Good  results  from  iodide  of  potassium 
and  mercury  obtained  in  cerebro  spinal 
meningitis.  Judicious  nursing  and  at- 
tention to  small  and  various  details  is  of 
more  real  value  than  drugs.  Bristowe 
(Brain,  July.  '88). 

Case  of  acute  simple  meningitis  cured. 
He  was  treated  freely  with  mercury  under 
Iho  direction  of  Broadbent.  J.  J.  Clark 
(Brit.  Med.  Jour.,  June  8,  '80). 


Experiments  on  dogs  showing  that  by 
subdural  injections  of  1  in  4000  sublimate 
solution  tuberculous  meningitis  may  not 
only  be  alleviated,  but  cured.  Mannotti 
(II  Policlinico,  Aug.  1,  '95). 

Literature  of  '96-'97-'98. 

Good  results  from  mercury  in  nine 
cases  of  cerebro-spinal  meningitis  occur- 
ring in  an  epidemic  of  grip.  Only  one 
case  proved  fatal.  Dose  varied  from  Via 
to  V-  grain  of  the  bichloride,  according 
to  the  age  of  the  patient,  administered 
hypodermic-ally  once  in  twenty-four 
hours  in  the  beginning  and  later  once  in 
forty-eight  hours.  Consalvi  (La  Sem. 
Med.,  Jan.  15,  '90). 

Uniform  success  with  mercury  in 
cerebro-spinal  meningitis;  V*  grain  of 
mercuric  chloride  is  given  hypodermically 
at  first  and  then  Vis  grain  every  hour 
until  there  are  symptoms  of  gastro- 
intestinal irritation.  Smith  (Jour.  Amer. 
Med.  Assoc.,  June  13,  '96). 

Method  of  Dazio  in  treating  meningitis 
with  hypodermic  and  intravenous  injec- 
tions of  mercuric  chloride  successfully 
employed.  Dinami  (La  Pediatria,  Nov., 
'97). 

The  surgical  treatment  is  limited  to 
those  cases  of  simple  purulent  leptomen- 
ingitis in  which  the  disease  is  localized 
and  accessible  to  the  trephine.  Among 
American  surgeons  Senn  and  Keen  ad- 
vise trephining  in  tubercular  cases  and 
washing  out  the  exudate  with  antiseptic 
solutions.  *  Cases  arising  from  aural  and 
mastoid  suppuration  may  require  sur- 
gical measures.  It  should  be  remem- 
bered that  the  inflammation  in  such  cases 
is  sometimes  on  the  opposite  side  of  the 
brain,  as  in  a  case  referred  to  by  Charles 
K.  Mills  in  his  work  on  nervous  diseases. 
In  such  cases  special  study  must  always 
be  given  to  any  localizing  signs  present. 
Lumbar  puncture  has  been  practiced  by 
Quincke  in  cases  of  serous  leptomenin- 
gitis, both  for  diagnostic  purposes  and 
the  relief  of  intracranial  tension. 

Four  cases  of  tubercular  meningitis 
operated  upon  by  paracentesis  of  the 


MENINGITIS.    CHRONIC  LEPTOMENINGITIS  (CEREBRAL). 


577 


theca  vertebra tis,  with  the  object  of  re- 
lieving pressure  from  accumulated  fluids. 
There  was  temporary  amelioration  of 
symptoms,  although  all  the  cases  ended 
fatally.   E.  Wynter  (Lancet,  May  2,  '91). 

Death  in  tubercular  meningitis  caused 
not  by  the  development  of  tubercles,  but 
by  intracranial  compression,  by  cerebral 
asphyxia.  Rational  treatment,  therefore, 
is  trephining  and  drainage.  Case  of  re- 
covery. R.  Hirschberg  (Bull.  gen.  de 
Ther.,  Nov.  15,  '94). 

Space  between  laminae  of  lumbar  verte- 
brae best  in  children,  but  in  adults  space 
between  last  vertebra  and  sacrum  best. 
Chipault  (Revue  Neurol.,  p.  11,  '95). 

Case  of  tubercular  meningitis  in  which 
puncture  caused  aggravation.  Lenhartz 
(Lancet,  Oct.  19,  Nov.  9,  '95). 

Three  cases  of  tubercular  meningitis 
unsuccessfully  treated  by  subdural  drain- 
age. R.  H.  Russell  (Intercol.  Quarterly 
Jour,  of  Med.  and  Surg.,  Aug.,  '95). 

Literature  of  '96-'97-'98. 

Puncture— in  a  case  of  tuberculous 
meningitis  in  a  child  of  13  months — suc- 
ceeded in  checking  the  convulsions  and 
bringing  about  a  peaceful  termination 
twenty-four  hours  later.  Lazard  (Jour, 
de  Clin,  et  de  Ther.  Infant.,  May  7,  '96). 

Lumbar  puncture  employed  in  25  cases, 
including  19  of  tuberculous  meningitis. 
In  no  case  as  yet  has  the  puncture  pro- 
duced a  cure.  A  fatal  result  occurred 
in  all  19  cases  of  tuberculous  meningitis. 
No  improvement  seen  in  the  optic  neu- 
ritis. Lumbar  puncture  can  only  be  of 
very  limited  diagnostic  value  in  tuber- 
culous meningitis.  The  differential  diag- 
nosis between  it  and  the  meningitis  con- 
secutive to  ear  disease  has  not  always 
been  made  easy  by  spinal  puncture.  In 
tuberculous  meningitis  the  fluid  drawn 
off  is  clear,  usually  colorless,  but  it  may 
be  very  slightly  green  or  yellow.  The 
specific  gravity  was  about  1010,  and  the 
amount  of  albumin  1  to  1.5  pro  mille. 
Traces  of  sugar  were  present.  The 
amount  of  fluid  drawn  off  was  usually 
from  20  cubic  centimetres  to  30  cubic 
centimetres,  and  the  pressure  high, 
amounting  to  160  millimetres  to  300 
millimetres  water.  V.  Ranke  (Miinch. 
med.  Woch.,  Sept.  21,  '97). 

4 


Case  of  tubercular  meningitis  followed 
by  recovery  after  lumbar  puncture.  The 
diagnosis  of  tubercular  meningitis  was 
made,  lumbar  puncture  was  performed, 
and  about  ten  cubic  centimetres  of  clear 
fluid  were  slowly  withdrawn.  Tubercle 
bacilli  were  found,  thus  establishing  the 
diagnosis.  N.  L.  Stowell  (Pediatrics,  vol. 
iv,  p.  415,  '97). 

Lumbar  puncture  is  without  great 
therapeutic  value.  Even  in  so-called 
serous  meningitis  only  one  of  the  four 
cases  upon  which  it  was  practiced  showed 
any  good  results  from  the  operation. 

Puncture  was  done  15  times  in  12  cases 
of  tubercular  meningitis,  and  the  bacilli 
were  found  9  times  in  8  patients;  while 
of  5  punctures  in  2  cases  of  epidemic 
cerebro- spinal  meningitis  only  1  yielded 
the  Weichselbaum  coccus. 

In  4  cases  of  purulent  meningitis  pus- 
corpuscles  and  streptococci  were  found  in 
the  fluid  of  2,  streptococci  without  pus 
in  1,  and  many  white  blood-corpuscles 
without  micro-organisms  in  the  fourth. 

Even  when  lumbar  puncture  is  an  un- 
doubted diagnostic  aid,  the  information 
thus  obtained,  considering  the  present 
status  of  therapeutics,  is  not  of  great 
practical  value.  Fleischmann  (Deut. 
Zeits.  f.  Nerv.,  July,  '97). 

Case  of  chronic  infantile  meningitis 
with  nasal  drainage.  About  2  1/2  ounces 
of  clear  fluid  escaped  and  the  child  ap- 
peared somewhat  better.  But  on  the 
twelfth  day  after  operation  the  child  be- 
came weaker  and  death  followed  on  the 
twenty-third  day.  Walker  Overend  and 
W.  Foster  Cross  (Lancet,  Oct.  29,  '98). 

Chronic  Leptomeningitis  (Cerebral). 

Definition.  —  Chronic  cerebral  lepto- 
meningitis is  a  chronic  inflammatory  af- 
fection of  the  pia  arachnoid,  associated 
with  a  great  variety  of  clinical  symptoms, 
according  to  the  location,  extent,  and 
g-rade  of  the  inflammation.  The  dura 
and  brain-substance  are  very  frequently 
coincidently  affected. 

Varieties. — Tin's  disease  occurs  in  the 
large  majority  of  cases  in  patients  past 
middle  life,  but  an  infantile  form  is  de- 
scribed by  Gee  and  Barlow  and  others  in 
-37 


578      MENINGITIS.    CHRONIC  LEPTOMENINGITIS  (CEREBRAL).  SYMPTOMS. 


which  the  posterior  fossa  is  usually  the 
seat  of  the  inflammation.  In  location 
the  disease  may  affect  any  portion  of  the 
membranes,  but  its' most  frequent  site  is 
the  vertex.  The  exudate  found  in  such 
cases  may  consist  of  serum,  pus,  lymph, 
or  dense  connective  tissue. 

The  chief  clinical  varieties  are:  1. 
A  very  numerous  class  of  the  chronic  in- 
sane. 2.  Cases  following  chronic  alco- 
holism, syphilis,  tuberculosis,  and  gout. 
3.  Infantile  cases  arising  from  acute 
leptomeningitis,  inherited  syphilis,  or 
tuberculosis.  The  chief  causes  of  all  cases 
are  syphilis,  tuberculosis,  chronic  alco- 
holism, traumatism,  sun-stroke,  and  pre- 
vious attacks  of  congestion  or  inflamma- 
tion of  the  arachnopia. 

Symptoms. — The  symptoms  of  chronic 
leptomeningitis  will  vary  almost  indef- 
initely, as  already  remarked,  with  its 
location,  extent,  and  severity,  and  the 
general  condition  of  the  patient  affected. 
The  symptoms  noted  in  infantile  cases 
have  been  stupor  of  some  grade,  occa- 
sional vomiting,  headache;  rapid,  irreg- 
ular, or  slow  pulse;  diplopia,  strabismus, 
ptosis,  irregularity  of  the  pupils,  and 
slight  fever.  In  some  cases  active  vomit- 
ing, decided  fever,  cervical  opisthotonos, 
and  spastic  limbs,  with  occasional  con- 
vulsions, have  been  recorded.  There 
may  be  hemiplegia  or  bilateral  paresis  or 
paralysis.  The  face  is  sometimes  in- 
volved alone.  All  the  signs  are  devel- 
oped w  ith  great  irregularity,  and  the  dis- 
ease runs  a  very  irregular  course  through- 
out. 

Chronic  leptomeningitis  is  far  more 
frequently  seeu  in  male  adults,  and  in 
old  age,  and  especially  among  tin1  insane 
it  is  a  very  frequent  post-mortem  find- 
ing. The  symptoms  observed  during  life 
may  be  any  form  of  chronic  menial  dis- 
ease, but  it  is  particularly  common  in 
general  paresis,  chronic  mania,  and  in 


I  terminal  dementia  following  all  forms  of 
insanity.    The  exact  relationship  of  the 
lesions  of  chronic  leptomeningitis  found 
|  so  often  in  insane  subjects  is  still  a  mat- 
ter of  some  doubt,  regarding  their  im- 
portance as  causes  of  the  mental  disorder. 
Certain  forms  of  chronic  leptomeningitis 
are  undoubtedly  merely  an  evidence  of 
!  the  wide-spread  degeneracy  of  the  vas- 
|  cular  system,  and  of  the  very  low  general 
vitality  of  all  the  tissues  of  the  body. 
In  some  cases  following  traumatism 
J  this  lesion  is  probably  the  physical  cause 
j  of  the  symptoms  observed  during  life, 
j  The  blow  upon  the  head  which  cause- 
chronic  inflammation  of  the  membranes 
is  more  frequently  not  attended  by  fract- 
ure, but,  from  the  history  given,  has 
been  sufficiently  violent  to  cause  uncon- 
sciousness.   Months  or  even  years  may 
elapse  before  definite  cerebral  symptoms 
occur.     When  they  develop  they  may 
simulate  almost  any  form  of  insanity, 
I  but,  during  the  course  of  the  disease,  the 
I  mental  symptoms  are  apt  to  be  variable 
!  and  irregular,  when  compared  with  typ- 
ical cases  of  the  kind  simulated  by  the 
j  traumatic  affection.    Some  form  of  pa- 
resis or  paralysis  may  occur  early  or  late, 
but  is  not  constant.    Pain  in  the  head 
j  is  the  most  constant  feature,  and  if  this 
occurs  for  weeks  associated  with  mental 
depression  or  exaltation  and  a  history  of 
traumatism  of  the  vertex  of  the  skull, 
chronic  leptomeningitis  may  be  suspected 
at  the  point  of  injury. 

The  traumatic  cases  are,  however,  very 
few  in  number  compared  with  the  great 
frequency  of  the  lesions  of  chronic  lepto- 
meningitis in  hospitals  for  the  insane. 
The  importance,  however,  of  the  recog- 
nition of  the  traumatic  east's  has  led  me 
to  mention  it  prominently,  and  to  lav 
stress  upon  its  occasional  occurrence 
without  definite  localizing  symptoms; 
because  very  frequently  the  prefrontal 


MENINGITIS.    CHRONIC  LEPTOMENINGITIS  (CEREBRAL).    PATHOLOGY.  579 


or  the  post-parietal  region  is  the  site  of 
the  injury,  thus  giving  us  few  motor 
symptoms,  unless  the  process  extends  be- 
yond the  limits  of  the  original  trauma- 
tism. 

The  clinical  history  of  cases  of  chronic 
leptomeningitis  may  present  signs  of 
either  basal  or  vertical  origin,  or  focal 
symptoms  may  be  present,  especially  in 
the  syphilitic  cases.  The  symptoms  do 
not  depend  upon  the  character  of  the 
cause  producing  the  trouble,  but  simply 
upon  the  local  lesion  and  its  location,  in- 
tensity, and  extent.  There  is  no  definite 
clinical  picture  to  present,  and  the  symp- 
toms noted  are  those  common  to  several 
other  conditions.  It  is  only  when  con- 
sidered in  connection  with  the  history  of 
the  case  and  with  their  mode  of  develop- 
ment and  course  that  they  can  point 
with  any  certainty  to  this  disease.  The 
symptoms  in  adults  or  old  age  include 
persistent  headache,  usually  dull  and 
aching,  but  at  times  complained  of  as 
sudden  shooting  pains  through  the  head, 
and  in  other  cases  it  may  be  localized 
dull  and  boring;  rapidly  increasing  de- 
bility, with  loss  of  flesh  in  the  old,  with 
or  without  paresis  of  the  limbs;  profound 
mental  depression,  or  stupor,  or  mere 
apathy  or  varying  degrees  of  mental  ex- 
altation in  younger  subjects  especially; 
attacks  of  vertigo  or  syncope;  occasional 
attacks  of  causeless  nausea  and  vomiting; 
optic  neuritis  may  be  present,  but  is 
often  absent;  more  decided  symptoms 
may  exist  when  the  cortex  itself  is  in- 
volved, as  in  a  case  reported  by  Mills, 
presenting  "athetoid  spasm,  myotomia, 
and  diffuse  bilateral  disturbances  of  sen- 
sation, which  was  found  to'  bo  due  to 
chronic  convexity,  meningitis  of  both 
hemispheres  with  cortical  and  subcor- 
tical  softening,  the  lesion  being  most 
marked  in  the  postoro-parietal  region." 
This  case  also  had  recurring  attacks  of 


Jacksonian  epilepsy.  It  is  impossible 
within  the  limits  of  this  paper  to  give 
more  than  the  merest  glimpse  of  the 
wide  range  of  symptoms  which  occur  in 
these  cases  of  chronic  leptomeningitis. 
Fully  one-half  of  the  cases  are  secondary 

I  to  other  affections  of  the  brain  or  to  the 
bodily  manifestations  of  one  or  other 
of  the  diatheses  already  referred  to  as 
etiological  factors.    Thus,  its  symptoms 

I  may  complicate  those  of  brain-tumor  or 
brain-abscess,  traumatism,  embolism  and 
thrombosis,  and  cerebral  atrophy;  or 
they  may  arise  in  the  course  of  general 
tuberculosis,  or  as  the  tertiary  stage  of 
syphilis. 

Etiology. — Chronic  cerebral  leptomen- 
ingitis arises  (1)  in  infancy  or  childhood 
from  inherited  disease  or  an  acute  attack 
J  drifting  into  a  chronic  conditon,  well  de- 
scribed by  Gee  and  Barlow.  (2)  Certain 
other  cases  may  arise  acutely,  including 
the  traumatic  type  of  the  disease,  which 
can  quite  frequently  be  traced  directly 
to  a  definite  injury  at  the  position  of  the 
lesions  found  post-mortem.  (3)  The 
largest  number  of  all  cases  in  adults  are 
due  to  structural  alterations  dependent 
upon  antecedent  syphilis,  tuberculosis, 
chronic  alcoholism,  rheumatism,  and 
gout,,  and  a  large  proportion  of  the  cases 
become  insane  at  some  stage  of  the  dis- 
order. 

The  view  is  now  quite  commonly  held 
j  that  infection  occurs  in  these  cases  as 
the  causative  factor.    This  is,  however, 
by  no  means  proved,  and  is  largely  con- 
jectural. 

Pathology. — The  post-mortem  appear- 
ances vary  a  great  deal  according  to  the 
duration  of  the  disease  and  the  nature  of 
the  inflammation. 

Tuberculosis  chiefly  affects  tin1  base, 
although  its  lesions  may  appear  anywhere 
else  over  the  surface  of  the  hemispheres, 
i  The  syphilitic  lesions  appear  as  more  or 


580     MENINGITIS.    CHRONIC  LEPTOMENINGITIS  (CEREBRAL).  TREATMENT. 


less  cheesy,  gummatous,  or  fibroid  lesions 
which  at  times  invade  the  cortex.  When 
the  inflammation  is  of  a  simple  character 
most  of  the  lesions  are  of  connective-tis- 
sue deposits  in  the  pia  and  especially 
noticeable  in  their  effect  upon  the  blood- 
vessels, which  may  be  greatly  thickened 
and  even  obliterated  in  areas. 

When  the  cases  are  of  less  duration 
the  exudate  may  be  pus  or  sero-puru- 
lent  matter  mixed  with  poorly-organized 
patches  of  lymph.  Cases  are  numerous 
in  which  the  cerebral  membranes  are 
closely  matted  together  by  connective- 
tissue  adhesions,  and  in  such  cases  the 
dura  may  be  firmly  adherent  to  the  skull 
and  the  pia  less  firmly  to  the  brain-sub- 
stance. The  choroid  plexuses  and  the 
ependyma  frequently  show  marked  le- 
sions, and  at  times  are  covered  by  a 
lymphatic  or  purulent  aexudate.  The 
veins  are  commonly  overdistended  with 
blood,  but  in  long-standing  cases,  in 
which  there  is  almost  always  a  marked 
atrophy  of  the  brain,  a  compensating 
oedema  of  the  membranes  is  usually  pres- 
ent, and  this  serous  exudate  may  be  so 
abundant  as  to  exert  sufficient  pressure 
upon  the  blood-vessels  to  empty  them 
and  cause  a  post-mortem  appearance  of 
extreme  cerebral  anaemia.  In  marked 
cases  of  this  kind  the  pia-arachnoid 
may,  in  its  oedematous  condition,  be 
fully  one-half  inch  thick  over  the  su- 
perior surface  of  the  brain  and  much 
thicker  when  it  dips  down  into  the  cere- 
bral fissures  and  sulci.  In  other  cases  no 
oedema  is  present,  but  scattered  patches 
of  white  fibroid  thickening  arc  scattered 
over  the  surface  of  the  pia,  or  along  the 
cranial  nerve-roots  at  the  base.  The 
location  of  these  often  explain  special 
points  in  the  symptomatology  during 
life.  Bevan  Lewis  states  that  thickening 
of  the  pia  mater  is  present  in  nearly  one- 
half  of  the  autopsies  upon  insane  persons. 


I  and  my  experience,  as  pathologist  at  the 

I  Morris  Plains  Hospital  for  the  Insane, 

!  fully  corroborates  his  estimate  of  the 
great  frequency  of  this  lesion  in  insanity. 
It  is  probable  that  the  chronic  innamma- 

j  tory  changes  above  referred  to,  when  oc- 
curring in  this  class  of  patients,  together 
with  the  oedema  and  cerebral  atrophy. 

|  are  all  links  in  the  chain  of  degenerative 
changes,  which  are  primarily  due  to  path- 
ological alterations  in  the  walls  of  the 
blood-vessels.  In  the  tubercular  and 
syphilitic  cases,  and  in  those  cases  due 

i  to  chronic  alcoholism  and  traumatism, 
the  same  cannot  be  said,  for,  although  it 
is  true  that  the  lesions  themselves  are 
most  frequently  secondary,  they  have,  in 
such  cases,  a  much  greater  causal  relation 
with  the  symptoms  observed  during  life. 

Prognosis.  —  The  prognosis  is  very 
grave  in  all  these  cases.  Early  recogni- 
tion of  the  condition  is  important,  and 
may  result  in  the  cure  of  some  cases, 
especially  among  those  of  syphilitic  ori- 
gin. Operation  in  focal  lesions  due  to 
traumatism  may  likewise  effect  a  cure, 
but  the  outlook  in  the  vast  majority  of 
cases  is  bad,  for  they  rarely  come  under 
observation  until  the  lesions  in  the  mem- 
branes are  advanced,  and  their  secondary 
injurious  effects  upon  the  brain  clearly 
well  marked. 

Treatment.  —  The  patient  in  whom 
chronic  leptomeningitis  is  suspected 
should  be  relieved  of  all  care  and  worry 
as  far  as  possible.  The  hygiene  and  diet 
should  be  strictly  regulated.  The  exer- 
cise should  be  suited  to  the  physical  con- 
dition of  the  patient,  and  the  general 
vitality  increased  in  every  possible  man- 
ner. Tonics,  good  food,  massage,  elec- 
tricity, and  the  careful  regulation  of  the 

|  bodily  secretions  are  the  chief  means  at 
our  disposal.  The  man  who  has  been 
overworked  should  have  complete  change 

I  of  air  and  scene,  and  for  the  otherwise- 


MENINGITIS.    SPINAL  MENINGITIS. 


581 


healthy  cases  a  long  trip  to  the  woods  of 
northern  Maine  or  Canada  during  the 
summer  and  early  fall  sometimes  proves 
of  great  value  in  so  changing  the  nutri- 
tion of  the  patient,  and  increasing  the 
vital  resistive  element  of  the  system  to 
such  a  degree,  that  a  markedly  favorable 
impression  is  made  upon  the  chronic 
meningeal  inflammation,  which  is,  as  we 
have  seen,  too  often  of  the  nature  of  a 
degeneration,  in  that  it  usually  occurs 
coincidentally  with  other  degenerative 
changes. 

The  other  indications  are  to  relieve 
headache  when  present,  and  diminish,  if 
possible,  the  local  lesions.  In  syphilitic 
cases  treated  early  there  is  hope  of  real 
or  relative  cure,  or  of  great  improvement 
in  other  cases  if  the  general  health  will 
permit  of  mercury  and  the  iodides.  In 
cases  permitting  their  free  use,  they 
should  be  given  in  full  doses  to  their  de- 
cided physiological  limit.  In  weak  cases 
small  doses  must  be  given,  and  even  these 
are  sometimes  poorly  borne. 

Traumatic  cases  demand  careful  study 
to  decide  whether  an  operation  should  be 
done.  This  should  only  be  performed 
when  from  the  localizing  symptoms  there 
is  sufficient  hope  of  relieving  irritation 
or  pressure  symptoms  to  warrant  the  risk 
of  trephining.  When  clearly  focal  men- 
ingeal symptoms  occur  after  traumatism 
and  at  the  point  of  injur}^  the  trephine 
should  be  used,  and  if  thickened  and  in- 
durated membrane  is  found  the  fibroid 
tissue  should  be  excised.  At  times  the 
mere  removal  of  a  button  of  bone  will 
relieve  the  symptoms,  probably  by  relief 
of  intracranial  tension. 

Counter-irritation  is  advised,  by  some 
writers,  by  cautery  or  seton  to  the  back 
of  the  neck.  Frequent  hot  baths  may  be 
tried  in  suitable  cases.  Ergot  and  bro- 
mides are  said  to  be  useful,  and  do  aid  in 
relieving  pain.    For  insomnia  it  is  best 


to  avoid  opium,  and  employ  sulphonal, 
trional,  or  a  mixture  of  chloral  and  bro- 
mide of  sodium.  While,  in  general,  ad- 
vanced cases  yield  small  returns  to  treat- 
ment, some  cases  of  chronic  leptomenin- 
gitis will  be  found  in  which  persistent 
careful  treatment  will  amply  repay  the 
effort  by  the  most  gratifying  results. 
Spinal  Meningitis. 

Spinal  meningitis  means  inflammation 
of  the  meninges  of  the  spinal  cord.  The 
same  general  anatomical  and  patholog- 

j  ical  conditions  govern  inflammation  of 
the  membranes  of  the  spinal  cord  as  have 
been  referred  to  in  connection  with  cere- 
bral meningitis.  Thus,  inflammation  of 
the  spinal  membranes  may  be  divided 
into  (1)  pachymeningitis,  which  may  be 
external  or  internal  in  its  location;  and 

!  (2)  leptomeningitis,  which  may  be  acute 
or  clironic.  Just  as  in  the  brain,  inflam- 
mation of  any  one  of  the  spinal  mem- 
branes may  spread  to  and  include  the 
others,  or  the  substance  of  the  spinal 

|  cord  itself  may  be  involved,  and  this 

[  meningomyelitis  corresponds  in  its  eti- 
ology and  pathology  to  meningoenceph- 
alitis occurring  so  often  in  the  brain  as 

[  a  result  of  primary  inflammation  of  the 
membranes.  Clinically  and  pathologic- 
ally it  is  impossible  to  always  draw  dis- 
tinctions between  inflammatory  states  of 
the  spinal  membranes,  and  this  classifica- 

I  tion  of  the  subject  upon  a  purely  ana- 
tomical basis  is  somewhat  misleading, 
although  for  purposes  of  conciseness  and 
clearness  of  description  it  has  been  fol- 

I  lowed  by  writers  upon  the  subject. 
External  Spinal  Pachymeningitis. 
Definition.  —  External  spinal  pachy- 
meningitis means  inflammation  of  the 
outer  layer  of  the  spinal  dura  mater.  It 
is  a  secondary  affection. 

Symptoms.  —  These  will  depend  upon 

|  the  location  and  extent  of  the  pachymen- 

|  ingitis.    There  is  tenderness  over  the  af- 


fected  portion  of  the  spine,  pain  radiat- 
ing over  the  spinal  nerves  involved, 
hyperesthesia  and  spasm  of  the  skin  and 
muscles  supplied  by  them,  changing  to 
complete  anaesthesia  and  paralysis  should 
the  inflammation  be  a  destructive  one, 
or  if  the  nerves  are  functionally  cut  off 
by  pressure  of  the  exudate.  In  extreme 
cases  the  spinal  cord  in  compressed,  and 
we  may  have  spastic  paraplegia,  and 
other  evidences  of  pressure.  A  secondary 
myelitis  is  often  set  up  by  the  same  cause 
producing  the  pachymeningitis,  and  the 
symptoms  of  the  lesions  are  often  asso- 
ciated. 

Diagnosis.  —  This  depends  upon  the 
recognition  of  the  cause.  In  obscure 
cases  it  may  be  taken  for  myelitis,  with 
which  it  is  frequently  associated  as  com- 
pressive myelitis.  A  review  of  the  his- 
tory of  pain,  hypersesthesia  extending 
over  some  weeks  or  months,  with  final 
development  of  paralytic  symptoms,  sep- 
arates the  affection  from  myelitis,  with 
its  girdle  sensation,  decided  onset,  and 
early  paralysis. 

Etiology. — The  chief  causes  of  spinal 
pachymeningitis  is  caries  of  the  spinal 
vertebra1,  as  in  vertebral  tuberculosis, 
Pott's  disease,  and  from  tumors  or  ab- 
scesses pressing  on  the  spinal .  column 
and  causing  erosion  of  the  vertebrae.  It 
may  also  arise  from  collections  of  pus  in 
the  pleura,  peritoneum,  and  posterior 
mediastinum. 

Case  of  spinal  caries  with  pachymen- 
ingitis involving  the  dorsal  and  cauda- 
equinal  regions.  Cheesy  nodules  were 
found  in  both  lungs  and  thickened 
patches  of  dura,  on  which  were  cheesy 
nodules  that  pressed  upon  1  he  cord.  The 
arms  and  legs  had  been  paraly/ed,  con- 
tracted, and  atrophied.  Sinkler  (Jour,  of 
Nerv.  and  Mental  Dis..  June,  '90). 

Case  of  cerebro-spinal  meningitis  of 
tubercular  origin,  beginning  in  the  inter 
nal  surface  of  the  dura  mater  of  the  cord 


and  only  involving  the  bone  secondarily. 
Bewley  (Brit.  Med.  Jour.,  June  11,  '92). 

Pathology.  ■ —  The  affected  portion  of 
the  spinal  dura  in  cases  of  simple  trans- 
mitted irritation,  may  be  thickened  by 
organized,  newly-formed  connective  tis- 
sue. Very  frequently  in  tubercular  cases 
it  is  the  seat  of  suppuration  or  exhibits 
great  thickening  with  deposits  of  cheesy 

!  pus  here  and  there.    AM  ten  malignant 

I  tumor  is  the  cause,  it  may  be  indistin- 
guishable from  the  tumor-tissue. 

Prognosis. — The  prognosis  is  bad  un- 
less surgical  relief  can  be  afforded.  Cases 
caused  by  Pott's  disease  offer  the  most 
hope  of  recovery. 

Treatment.  —  This  will  depend  upon 
the  causes  mentioned  under  Etiology, 

I  and  the  reader  is  referred  to  the  sections 
devoted  to  them  for  a  full  description 
of  appropriate  therapeutic  and  surgical 
treatment.  The  majority  of  cases  arise 
from  spinal  caries;  so  that  the  treatment 
of  this  affection  is  practically  that  of 
Pott's  disease.     Counter-irritation  may 

I  be  used  from  time  to  time,  but  only  after 
the  spine  has  been  immobilized.  Tonics, 
and  a  life  in  the  air  and  sunshine  daily, 
are  valuable  aids  in  treatment. 
Internal  Spinal  Pachymeningitis. 
Definition.  —  internal  spinal  pachy- 
meningitis is  a  chronic  inflammation  of 
the  inner  surface  of  the  spinal  dura 
mater,  marked  frequently  by  coincident 
haemorrhage,  and  analogous  to  the  ccre- 
bra]  form  of  the  disease. 

Symptoms. — The  disease  begins  slowly 
and  no  very  marked  symptoms  denote 
the  beginning  of  the  disease.  Ilyper.TS- 
thesia  and  pain  over  the  spine,  or  at  the 
periphery  of  the  spinal  nerves  arising 
from  the  diseased  area,  may  he  for  a  long 
time  the  only  clinical  features  noted. 
As  the  disease  progresses  there  is  a 
gradually-developed    paresis,    with  at- 

I  rophy  of  the  muscles  supplied  by  these 


MENINGITIS.    SPINAL  MENINGITIS. 


583 


nerves,  together  with  a  corresponding 
distribution  of  anaesthesia.  When  the 
cord  is  compressed  by  the  exudate,  spas- 
tic  paraplegia  is  added  to  the  symptoms, 
or,  if  the  compression  is  in  the  cervical 
region,  all  the  muscles  below  that  point 
are  spastic  and  paretic.  The  reflexes  are 
increased  in  the  paralyzed  limbs.  Most 
of  the  cases  die  from  intercurrent  disease 
or  gradual  exhaustion,  frequently  added 
to  by  the  occurrence  of  bed-sores. 

Diagnosis. — The  diagnosis  from  myeli- 
tis may  be  difficult.  In  the  later  stages 
they  are  very  often  associated.  Symp- 
toms of  spinal-cord  irritation  are  more 
prominent  in  the  meningeal  affection, 
while  anaesthesia  and  paralysis  are  usu- 
ally more  complete  in  myelitis.  In  in- 
ternal spinal  pachymeningitis  the  onset 
is  slower,  and  the  developments  of  the 
more  severe  symptoms  of  the  affection  is 
much  more  delayed  than  in  ordinary 
cases  of  myelitis.  The  history  of  the  case 
is  important  in  diagnosis,  and  the  coin- 
cident existence  of  cerebral  symptoms 
may  assist  in  forming  an  opinion.  The 
pain  of  pachymeningitis  is  made  worse 
by  even  slight  movements,  while  that  of 
myelitis  is  not  influenced  by  movements 
of  the  body.  Rigidity  and  contractions 
of  muscles  are  far  more  common  in  in- 
ternal pachymeningitis,  while  inconti- 
nence of  the  bladder  and  rectum  is  a 
marked  feature  of  myelitis. 

Etiology. — This  lesion  is  found  in  gen- 
eral paresis  of  the  insane,  and  also  occurs 
as  a  result  of  syphilis,  traumatism,  ex- 
posure to  cold,  chronic  alcoholism,  and 
possibly  as  the  result  of  the  rheumatic 
or  gouty  diathesis.  Like  the  analogous 
brain  condition,  it  is  a  disease  of  the  male 
sex  in  the  vasl  majority  of  cases,  and 
occurs  chiefly  after  the  age  of  thirty 
years,  most  cases  occurring  between  the 
fori ietb  and  sixtieth  years. 

Pathology. — The  inner  surface  of  the 


dura  presents  the  same  lesions  which  are 
seen  in  the  brain  in  similar  conditions 
of  system.  There  is  great  thickening  of 
the  dura,  due  to  successive  layers  of 
pseudomenbranous  formation,  into  which 
small  or  large  haemorrhages  have  oc- 
curred from  time  to  time  during  the 
progress  of  the  disease.  The  disease  may 
be  found  throughout  the  whole  length  of 
the  spinal  cord,  or  it  may  be  limited  to 
a  few  inches  or  even  less.  The  circum- 
scribed form  of  the  affection  is  apt  to  be 
in  the  cervical  region. 

In  hypertrophic  pachymeningitis  and 
chronic  infarction  of  the  spinal  cord,  the 
pachymeningitic  deposit  extends  along 
the  small  vessels  into  the  substance  of 
the  cord.,  the  small  vessels  of  the  pe- 
riphery being  the  carriers  of  the  infarc- 
tion to  the  peripheral  layers  of  the  cord, 
which  are  thereby  destroyed;  while  by 
means  of  the  arteries  of  the  anterior 
longitudinal  fissure  the  destructive  sclero- 
sis invades  the  cells  of  the  anterior  horns 
and  brings  about  degeneration  of  the 
pyramidal  tracts,  commissural  fibres,  and 
the  fibres  of  the  anterior  root-zones,  ex- 
tending even  into  the  anterior  roots; 
the  latter,  however,  and  the  spinal-nerve 
roots  in  general,  are  chiefly,  and  directly, 
affected  by  the  external  pachymeningitic 
deposit.  The  foci  of  softening  are  the 
result  of  infectious  cellular  infiltration, 
as  was  the  pachymeningitic  process 
which  preceded  it.  Tuberculosis  and 
syphilis,  chiefly  the  latter,  are  probably 
in  most  cases  the  diseases  from  which 
the  pachymeningitis  develops.  Adam- 
kiewicz  (Wiener  med.  Presse,  Apr.  27, 
'90). 

Prognosis.  —  The  prognosis  is  bad  in 
almost  all  cases,  and  chiefly  because  of 
the  usually  broken-down  general  condi- 
tion of  the  patient.  A  few  cases  of  cure 
have  been  reported,  and  in  other  cases 
the  symptoms  may  possibly  be  arrested 
by  careful  and  persistent  treatment. 

Treatment. — The  same  general  meas- 
ures advised  in  cases  of  chronic  cerebral 
leptomeningitis  are  of  use  here,  and  the 


584 


MENINGITIS.    ACUTE  SPINAL  LEPTOMENINGITIS. 


reader  is  referred  to  the  paragraph  de- 
voted to  its  treatment.  The  earlier  the 
condition  is  suspected,  the  greater  the 
hope  of  relief  or  cure.  Locally,  coun- 
ter-irritation may  be  tried  by  means  of 
painting  the  spine  with  strong  tincture 
of  iodine  from  time  to  time,  or  by  means 
of  the  Paquelin  cautery  applied  over  the 
seat  of  the  suspected  lesion.  They  act 
favorably  upon  the  pain  and  tenderness 
present.  Internally,  if  the  patient's  con- 
dition will  bear  it,  specific  treatment 
should  be  cautiously  employed  in  syph- 
ilitic cases,  the  doses  being  gradually  in- 
creased. In  cases  presenting  signs  of  a 
localized  lesion,  the  question  of  surgical 
operation  may  be  considered,  which  is 
warranted  by  the  otherwise-hopeless  con- 
dition which  results  after  compression  of 
the  cord  is  established. 

Acute  Spinal  Leptomeningitis. 

Definition. — Acute  spinal  leptomenin- 
gitis means  an  acute  inflammation  of  the 
pia-arachnoid  of  the  spinal  cord;  but 
very  often  the  spinal  dura  mater  and  the 
spinal  cord  itself  are  also  affected  by 
contiguity.  The  view  is  now  general 
that  the  disease  is  almost  always  due  to 
infection,  as  is  the  case  in  cerebral  lepto- 
meningitis. 

Varieties. — The  chief  clinical  varieties 
are  (1)  cases  arising  from  the  infection 
.  of  epidemic  cerebro-spinal  meningitis, 
which  may  expend  itself  in  some  cases  on 
the  spinal  membranes  alone,  with  very 
slight  or  no  involvement  of  the  cerebral 
meninges;  (2)  sporadic  cases  of  the  same 
disease;  (3)  cases  apparently  due  to  dia- 
thetic conditions,  including  tuberculosis, 
syphilis,  and  rheumatism;  (4)  cases  aris- 
ing in  the  course  of  septicaemia,  pyaemia, 
and  other  acute  infectious  diseases;  (5) 
cases  due  to  direct  extension  of  the  in- 
flammation from  the  cerebral  mem- 
branes, usually  limited  to  the  cervical 
cord;  (6)  cases  following  traumatism  and 


surgical  operations  upon  the  spinal  col- 
umn. 

Symptoms. — Acute  spinal  leptomenin- 
gitis has  a  sudden  onset,  except  in  the 
syphilitic  and  tuberculous  cases,  which 
may  arise  less  abruptly  and  run  a  sub- 
acute course.  The  prodromes  are  usu- 
ally few  and  may  be  so  slight  as  to  es- 
cape notice.  Sometimes  there  is  a  gen- 
eral sense  of  being  unwell;  or  malaise, 
with  restlessness,  may  be  complained  of; 
occasionally  there  is  a  history  of  vomit- 
ing for  some  days  prior  to  the  onset. 
When  the  onset  occurs  it  is  ushered  in 
by  a  severe  chill,  sharp  agonizing  pain 
in  the  back,  shooting  pains  in  the  limbs 
or  about  the  body,  with  fever,  vomiting, 
tenderness  along  the  spine,  easily  elicited 
by  percussion,  or  made  evident  by  hold- 
ing a  hot,  moist  sponge  over  the  spine. 
These  symptoms  are  followed  within  a 
few  hours  by  spasmodic  rigidity  of  the 
spinal  muscles,  retraction  of  the  head  if 
the  cervical  cord  is  involved,  and  flexion 
of  the  limbs  upon  the  trunk,  witli  very 
marked  rigidity  of  the  limbs.  The  ab- 
dominal muscles  are  contracted,  giving 
an  apparent  retraction  of  the  abdomen, 
and  the  chest-muscles  may  be  so  fixed  by 
spasm  as  to  cause  embarrassment  of  the 
respiration.  If  the  medulla  oblongata  is 
affected,  rapid,  irregular,  or  Cheyne- 
Stokes  respiration  may  be  observed,  with 
rapid  and  irregular  cardiac  action  due  to 
the  same  cause.  There  is  marked  gen- 
eral muscular  hyperesthesia,  and  any 
attempted  movement  of  the  limbs  adds 
greatly  to  the  sufferings  of  the  patient. 
The  pulse  may  be  very  rapid,  and  is  often 
most  irregular.  The  temperature  varies 
from  subnormal  to  104°  F.,  and  a  lower 
range  is  the  rule.  The  reflexes  are  di- 
minished except  at  the  beginning,  when 
they  may  appear  to  be  exaggerated.  The 
skin  may  be  flushed,  pale,  or  livid  in  np- 
pearance.    A  deep-red,  persistent  mark- 


MENINGITIS.    ACUTE  SPINAL  LEPTOMENINGITIS.  DIAGNOSIS. 


585 


ing  follows  the  pressure  or  stroke  of  the 
finger-nail  over  the  skin.  The  form  of 
paralysis  which  may  develop  after  the 
symptoms  above  noted  will  depend  upon 
the  location  of  the  inflammation  and  the 
affected  roots  of  the  spinal  nerves.  Usu- 
ally the  inflammation  is  wide-spread  and 
nearly  all  parts  of  the  spinal  membranes 
are  involved  in  the  process.  The  most 
common  type  of  paralysis  is  spastic  para- 
plegia, with  paresis  of  rectum  and  blad- 
der. This  form  in  cases  surviving  this 
period  presents  almost  identically  all  the 
symptoms  of  cross-myelitis,  and  as  the 
case  progresses  bed-sores  are  a  distressing 
feature  of  the.  case.  The  duration  of  the 
disease  is  from  a  few  days  to  a  few  weeks, 
when,  if  the  patient  survive,  a  slow, 
tedious  recovery  may  occur.  Eecovery  is 
nearly  always  coupled  with  some  degree 
of  paresis  or  paralysis,  which  is  very  per- 
sistent, and  too  often  permanent. 

Diagnosis.  —  The  diagnosis  of  acute 
spinal  leptomeningitis  is  sometimes  very 
difficult.  The  symptoms  of  spinal  irrita- 
tion observed  in  the  acute  infectious  dis- 
eases at  times  simulate  very  closely  this 
affection,  but  post-mortem  examination 
does  not  often  reveal  its  lesions.  The 
course  of  the  disease  in  these  pseudo- 
cases  will  generally  differentiate  them, 
for  it  is  at  the  beginning  of  such  spinal 
symptoms  that  the  mistake  is  liable  to  be 
made.  The  diagnosis  of  the  different 
forms  met  with  is  often  exceedingly  dif- 
ficult. The  presence  of  tuberculosis  in 
the  lungs  or  elsewhere  is  an  aid  to  diag- 
nosis, and  the  same  may  be  said  of  the 
known  presence  of  syphilitic  infection  or 
positive  active  lesions  of  this  disease. 
Cases  arising  during  epidemics  or  en- 
demics are  easily  recognized.  So  are  the 
cases  arising  from  traumatism,  opera- 
tions on  the  spine,  and  those  due  to  ex- 
tension from  the  cerebral  membranes,  j 
From  the  nature  of  the  post-mortem  ap- 


pearances it  is  seen  how  frequently  the 
spinal  cord  may  suffer  in  this  disease,  so 
that  in  the  later  stages  myelitis  is  fre- 
quently co-existent  with  it.  In  the  first 
of  the  illness  it  is  distinguished  from 
myelitis  by  the  paralysis  and  absence  of 
marked  pain  in  myelitis,  and  also  by  the 
very  variable  character  of  the  pulse  and 
temperature-curve  in  acute  leptomenin- 
gitis. 

Bacteriological  investigation  is  an  im- 
portant means  in  the  diagnosis  of  spinal 
meningitis.  This  bacteriological  obser- 
vation may  be  performed  by  taking  a 
small  quantity  of  blood  from  a  vein, 
putting  it  into  a  thermostat  warmed  to 
98.6°  F.,  and  leaving  it  there  for  ten  or 
twelve  hours.  If  the  diplococcus  is  pres- 
ent in  the  blood,  numerous  colonies  of 
these  micro-organisms  will  be  seen  upon 
the  surface  of  the  coagulum.  Bozzolo 
(Internat.  klin.  Rund.,  Mar.  31,  '89). 

Literature  of  '96-'97-'98. 

Only  4  cases  of  central  softening  of  the 
spinal  cord  in  syphilitic  meningitis  have 
been  described.  It  is  liable  to  be  mis- 
taken for  syringomyelia.  Case  of  female 
who  had  had  syphilis.  The  illness  began 
with  pain  in  the  back,  followed  by  head- 
ache, then  weakness  and  rigidity  of  legs. 
The  patellar  reflex  disappeared.  Later, 
painful  spasmodic  contractions  often 
occurred  in  right  leg,  and  later  still  girdle 
pains  became  troublesome.  The  legs 
finally  became  atrophied  and  completely 
paralyzed,  and  bed-sores  and  paralysis  of 
sphincters  developed.  Post-mortem  ex- 
amination disclosed  a  central  cavity, 
localized  to  the  gray  matter,  extending 
from  the  lower  lumbar  to  the  upper  cer- 
vical regions,  also  syphilitic  meningitis 
and  syphilitic  disease  of  the  vessels.  H. 
Wullenweber  (Munch,  med.  Woch.,  Aug. 
9,  '98). 

From  subdural  and  interspinal  haem- 
orrhage it  is  differentiated  by  the  groat 
suddenness  of  the  former  affections, 
which  instantly  produce  their  symptoms, 
and  always  follow  some  obvious  trau- 
matic cause.    Subdural  hremorrhage  is 


586 


MENINGITIS.    ACUTE  SPINAL  LEPTOMENINGITIS.  PATHOLOGY. 


usually  followed  by  some  grade  of  lepto- 
meningitis soon  after  its  occurrence. 

Etiology. — The  great  majority  of  cases 
arise  from  infection  of  the  pia-araclmoid, 
although  trie  source  of  the  infection  is 
often  difficult  or  impossible  to  trace. 
The  spinal  type  of  leptomeningitis  oc- 
curs quite  frequently  during  epidemics 
of  the  cerebro-spinal  form.  In  general 
practice  the  tubercular  form  is  the  one 
most  commonly  met  with.  Spinal  lepto- 
meningitis is  a  rare  complication  of  the 
acute  general  diseases,  such  as  pneumo- 
nia, typhoid  fever,  scarlet  fever,  yellow 
fever,  and  small-pox.  According  to 
Osier,  it  is  very  rare  in  pneumonia,  even 
when  cerebral  leptomeningitis  occurs, 
excepting  for  "the  first  two  or  three 
inches  of  the  cervical  region"  (Osier's 
"Practice  of  Medicine").  It  is  more  com- 
mon in  septicaemia  and  pyaemia.  Ex- 
posure to  cold  and  dampness  is  regarded 
as  a  cause  of  spinal  leptomeningitis  by 
some  writers. 

Pathology. — The  post-mortem  appear- 
ances vary  with  the  duration  of  the  case 
and  the  nature  of  the  inflammation. 
The  tendency  in  all  cases  is  to  spread, 
and  involve  the  whole  length  of  the 
spinal  canal,  but,  in  a  considerable  pro- 
portion of  cases  the  inflammatory  condi- 
tion is  limited  to  the  cervical  region. 
The  spinal  membranes  and  fluid  furnish 
excellent  conditions  for  the  growth  of 
pathogenic  bacilli,  and  for  this  reason 
wide-spread  lesions  are  usually  pres- 
ent. 

Cases  dying  within  a  few  days  present 
intense  congestion  of  the  pia-arachnoid, 
and  very  frequently  of  the  inner  surface 
of  the  dura  mater,  and  of  the  spinal  cord 
itself,  with  an  effusion  of  more  <>r  less 
turbid  serum:  or  the  exudate  may  con- 
sist of  sero-plastic  lymph.  In  other  cases 
the  exudate  is  purulent  and  very  abun- 
dant.   When  the  disease  has  a  duration 


I  of  a  week  or  two  the  autopsy  reveals 
grayish-white  opaque  pia  mater.  In 
cases  of  longer  duration  there  may  be  ad- 
hesions formed  between  the  arachnopia 

I  and  the  dura,  and  the  pia  may  be  abnor- 
mally adherent  in  places  to  the  spinal 
cord.  Tubercular  inflammation  here 
does  not  differ  from  that  already  de- 
scribed in  treating  of  tubercular  inflam- 
mation of  the  cerebral  membranes,  and 
the  syphilitic  form  of  the  disease  like- 
wise presents  the  same  kind  of  inflamma- 
tory changes  which  have  been  described 
as  syphilitic  leptomeningitis.  AH  of 
these  acute  inflammations  finally  attack 
the  nerve-roots  and  the  general  surface 
of  the  spinal  cord,  and,  even  in  cases 
which  do  not  show  any  macroscopic  le- 
sions, by  the  microscope  very  marked 
lesions  of  acute  inflammation  of  the 
nervous  elements  are  found.  The  axis- 
cylinders  of  the  nerves  are  swelled  and 
degenerated,  and  in  the  cord  there  is 
proliferation  of  neuroglial'  cells,  infiltra- 
tion of  leucocytes,  granular  degeneration 
of  nerve-fibres,  and  dilatation  of  the 

I  blood-vessels  and  their  sheaths  with  leu- 
cocytes. Various  forms  of  bacteria  have 
been  noted,  including  the  pneumococcus 
of  Friedlander  and  the  tubercle  bacillus. 
This  condition  of  meningomyelitis  exists 
in  some  degree  in  many  of  the  cases,  and 
at  times  may  be  so  marked  that  there  is 
seen  macroscopically  superficial  soften- 
ing of  the  spinal  cord  and  the  nerve- 
roots;  while,  in  cases  dying  after  the  dis- 
ease  has  become  chronic,  there  may  be, 
in  addition,  extreme  changes  of  the 
spinal  cord  and  the  nerve-roots,  from 
adhesions  formed  in  places  between  the 
adherent  arachnopia  and  the  dura.  In 
such  cases,  besides  the  superficial  soften- 
ing  of  the  cord,  there  is  found  parenchy- 
matous alterations  of  the  gray  substance 
or  foci  of  suppuration  in  other  parts  of 
the  cord. 


MENINGITIS.    ACUTE  SPINAL  LEPTOMENINGITIS.  TREATMENT. 


Literature  of  '96-'97-'98. 

In  epidemic  cerebrospinal  meningitis 
two  kinds  of  alternation  in  .the  cells  of 
the  spinal  cord  noted.  First,  slight 
changes  in  the  cells  of  the  anterior  horns, 
such  as  occur  from  various  poisons  and 
which  is  attributed  to  the  toxaemia  of 
the  disease,  viz.:  (1)  the  disappearance 
of  the  stainable  substance  of  Nissl  from 
dendrites  or  from  portions  of  the  den- 
drite or  of  a  eell--body;  (2)  the  forma- 
tion of  nodular  swellings  of  the  dendrites, 
these  swellings  corresponding  to  patho- 
logical accumulations  of  the  stainable 
substance;  and  (3)  a  tendency  to  dis- 
organization of  individual  Nissl  bodies, 
especially  at  the  periphery  of  the  cell. 
Second,  lesions  not  all  similar  to  the  first, 
but  practically  identical  with  those  which 
take  place  in  the  cell-body  of  a  neuron 
after  an  injury  of  the  axon  which  be- 
longed to  it.  These  latter  changes  were 
found  in  the  cells  of  the  anterior  horns 
and  in  those  of  Clarke's  columns.  L.  F. 
Barker  (Brit.  Med.  Jour.,  Dec.  25,  '97). 

Prognosis.  —  The  prognosis  is  always 
grave.  It  is  especially  serious  at  the  ex- 
tremes of  life,  which  bear  the  disease 
very  badly,  and  death  within  a  few  days 
is  the  most  frequent  termination  in  such 
cases.  The  rapidly-fatal  cases  are  char- 
acterized by  very  abrupt  onset,  high 
lever,  and  extensive  involvement  of  the 
spine,  including  the  cervical  regions. 
Cases  in  which  the  cervical  region  is  af- 
fected are  always  most  serious.  The  out- 
look in  traumatic  and  syphilitic  cases  is 
more  favorable,  and  recovery  may  in 
some  of  these  cases  be  fairly  perfect.  In 
the  other  cases,  even  when  recovery  oc- 
curs, secondary  spinal  lesions  may  result 
from  inflammation  and  degeneration  of 
areas  of  the  cord  itself. 

Treatment. — As  soon  as  possible  after 
the  onset  of  the  disease  the  patient 
should  be  put  to  bed,  resting  on  the  side, 
or,  as  advised  by  some  writers,  upon  the 
abdomen,  over  several  pillows  placed  un- 
der the  patient.    This  has  the  advantage 


of  permitting  applications  to  the  spine, 
but  is  not  always  borne  by  patients. 
Morphine  sufficient  to  control  the  ago- 
nizing pains  should  be  administered  at 
I  once  hypodermic-ally.  Prompt  applica- 
tions along  the  spinal  column  should  be 
made,  and  the  means  employed  may  in- 
clude wet  cupping,  leeches,  thermocau- 
tery, repeated  dry  cupping,  and  blisters. 
Leeches  should  not  be  used  in  the  cases 
of  young  children  or  in  weak  persons  of 
any  age,  but  should  be  reserved  for 
sthenic  subjects.  Dry  cups  are  a  valu- 
able measure  when  applied  vigorously 
and  repeatedly.  Care  should  be  exer- 
cised not  to  break  the  skin,  for  if  myelitis 
should  supervene  it  would  predispose  to 
the  formation  of  bed-sores.  If  well 
borne,  continuous  application  of  the 
spinal  ice-bag  is  a  valuable  measure.  At 
the  same  time,  internally  small  doses  of 
calomel  frequently  repeated  should  be 
given,  with  bromides  and  chloral  to  di- 
minish spinal  irritability.  A  very  valu- 
I  able  remedy,  which  is  often  very  effica- 
I  cious  in  allaying  pain,  and  probably  also 
acts  as  a  powerful  detergent,  is  the  hot 
bath  or  hot  pack. 

If  there  is  evidence  that  the  attack  is 
due  to  syphilis  or  rheumatism  as  under- 
lying causes,  specific  or  antirheumatic 
remedies  should  be  given  in  full  closes  at 
once.  Opium,  according  to  Stille  ("Epi- 
demic Cerebro-spinal  Meningitis,"  p. 
158,  ;67),  is  most  efficacious  in  epidemic 
cerebro-spinal  meningitis,  and  by  anal- 
ogy it  should  be  used  with  hope  of  good 
results  in  limiting  the  inflammation  as 
much  as  possible.  It  is  needed  usually 
for  the  excessive  pain  and  restlessness 
and  may  be  combined  with  the  bromides 
and  with  chloral.  Ergot  and  tincture  of 
belladonna  are  both  used  at  times  dur- 
ing the  acute  stage  to  contract  the  blood- 
vessels, but  the  former  is  more  useful,  in 
combination  with  the  iodide  of  potas- 


588 


MENINGITIS.    CHRONIC  SPINAL  LEPTOMENINGITIS. 


sium,  after  the  acute  stage  to  assist  in 
promoting  absorption,  while  the  value  of 
belladonna  in  such  cases  is  problematical. 
In  fact,  the  use  of  ergot  to  contract 
the  blood-vessels  of  an  inflamed  area  is 
largely  a  matter  of  clinical  habit,  and  no 
definite  proof  exists  that  it  really  has 
this  action  upon  the  inflamed  tissues. 

Should  the  patient  survive  the  acute 
stage,  milder  measures  of  counter-irrita- 
tion are  useful  in  keeping  up  a  detergent 
effect  upon  the  congested  spinal  cord. 
Hot  baths  may  be  continued,  and  the 
alternate  hot  and  cold  spinal  douche  is 
of  value  in  relieving  the  congestion. 

Massage  and  electricity  may  also  be 
used.  Internally  potassium  iodide  is  the 
best  absorbent.  It  should  be  combined 
with  mercurial  treatment  in  syphilitic 
cases.  Mercurial  inunctions  may  be  em- 
ployed along  the  spine.  They  also  do 
good  by  the  counter-irritation  caused  by 
them.  When  cerebral  s}rmptoms  arise, 
the  treatment  is  that  of  cerebro-spinal 
leptomeningitis,  which  has  already  been 
described. 

Chronic  Spinal  Leptomeningitis. 

Definition. — Chronic  spinal  leptomen- 
ingitis means  chronic  inflammation  of 
the  spinal  pia-arachnoid.  It  is  fre- 
quently associated  with  chronic  inflam- 
matory changes  of  the  adjacent  dura  and 
spinal  cord,  and  is  usually  a  sequence  of 
some  form  of  acute  spinal  leptomeningi- 
tis. 

Symptoms.  —  The  symptoms  in  lesser 
degrees  are  those  of  the  acute  form. 
Pain  in  the  back,  with  shooting  neuralgic 
pain  in  the  body  and  limbs,  and  frequent 
paresthesia  of  the  skin  over  correspond- 
ing areas  are  the  chief  symptoms.  Pa- 
ralysis is  infrequent  except  in  cases  where 
it  may  be  residual  from  the  primary 
acute  attack.  Eigidity  and  spasm  are 
not  marked  symptoms  of  the  chronic  dis- 
ease and  are  more  commonlv  absent.  In 


I  some  cases  few  symptoms  are  present 
during  life.  In  all  cases  the  symptoms 
are  very  indefinite.  Some  form  of  skin 
eruption  has  been  noted,  with  hyperaes- 
thesia,  pain,  and  some  rigidity  of  the 
|  spinal  muscles.  It  runs  a  ver}^  chronic 
I  course,  and  usually  exists  for  many  years 
prior  to  death. 

Diagnosis.  —  The  diagnosis  is  most 
often  obscure,  and  the  condition  can  only 
be  conjectured  from  the  group  of  symp- 
toms enumerated,  when  associated  with 
a  clinical  history  predisposing  to  the  con- 
dition. 

Etiology. — The  chief  etiological  feat- 
ures are  previous  attacks  of  leptomenin- 
gitis, chronic  alcoholism,  syphilis,  trau- 
matism, or  strain  of  the  spinal  column, 
and  as  a  complication  of  various  forms  of 
myelitis. 

Pathology. — The  post-mortem  appear- 
ances which  have  been  noted  are  thick- 
ening of  the  pia-arachnoid,  adhesions  of 
its  dura,  local  thickening  of  the  mem- 
branes enveloping  the  nerve-roots,  and 
adhesions  between  the  pia  and  the  spinal 
cord,  which  may  be  sclerosed  at  points 
where  adhesive  bands  are  attached  to  it. 

Prognosis. — Recovery  from  this  form 
I  is  doubtful  and  probably  never  occurs, 
the  disease  slowly  progressing  until 
death. 

Treatment. — The  treatment  is  symp- 
tomatic. Mild,  intermittent  counter-irri- 
tation may  be  used  with  benefit  in  re- 
lieving the  pain.  Internally  the  iodide 
|  of  potassium  may  be  given  in  doses  com- 
mensurate with  the  general  condition  of 
the  patient  and  with  the  existence  or  not 
of  a  syphilitic  history.  Tonics  and  all 
measures  tending  to  improve  the  sys- 
temic condition  of  the  patient  are  usu- 
ally necessary  to  these  cases. 

Cir.vTu.i-s  M.  Hay. 

Philadelphia. 


MENOPAUSE,  DISORDERS  OF. 


589 


MENOPAUSE,  DISORDERS  OF. 

General  Considerations. — All  the  or- 
ganic diseases  of  various  kinds  begin  to 
show  their  full  effects  at  about  45  to 
50  years.  If  a  woman's  organs  are  not 
all  sound,  she  is  apt  to  break  down  at 
this  age;  on  the  other  hand,  if  there  are 
no  organic  disorders,  abnormal  condi- 
tions do  not  develop,  and  the  woman 
who  was  healthy  before  remains  healthy 
throughout  the  climacteric  period. 

In  women  whose  nutrition  is  uniformly 
approximated  to  the  normal  standard, 
and  who  reach  this  period  unhampered 
by  pre-existing  ailments,  the  final  cessa- 
tion of  menstruation  occurs  without  ma- 
terial disturbance  of  the  functional  har- 
mony and  is  often  of  cosmetic  advantage. 
The  association  of  morbid  conditions  with 
the  menopause  is  accidental  and  the  re- 
sult, usually,  of  antecedent  causes,  espe- 
cially of  unphysiological  living.  The  in- 
fluence of  perfect  nutrition  and  natural 
living  during  the  premenstrual  and  ado- 
lescent years  upon  the  after-life  of  women 
is  of  the  most  salutary  and  far-reaching 
kind.  A.  H.  Bigg  (Amer.  Medico-Surg. 
Bull.,  Jan.,  '93). 

The  menopause  is  a  diverted  trophic 
nervo-vascular  force,  a  readjustment  of 
nutritive  forces,  not  life-endangering  in 
itself.  J.  S.  Nowlin  (Nashville  Jour,  of 
Med.  and  Surg.,  Jan.,  '95). 

The  various  malignant  diseases,  which 
are  prone  to  show  themselves  at  about 
the  time  of  the  change  of  life,  are  often 
attributed  to  menopause  as  an  entity; 
but,  in  truth,  the  vitality  with  which  we 
are  endowed  is  always  diminishing,  the 
reserve  force  is  lessening,  and  at  an  age 
varying  from  45  to  55  years  there  is  very 
little  margin  to  draw  upon.  This  is  not 
confined  to  women,  however,  for  it  is 
seen  in  the  fact  that  men  are  not  ac- 
cepted for  enlistment  above  the  age  of 
forty-five,  while  at  sixty  they  may  also 
be  said  to  undergo  a  "change  of  life." 

The  menopause,  properly  speaking,  is 
only  one  feature  of  the  change  of  life. 
The  woman  is  no  longer  strong  enough 


to  bear  and  rear  children,  except  in  com- 
paratively few  cases.  She  has  not  the 
vitality  to  endure  the  continually  re- 
curring drain  of  menstruation,  and  this 
function  ceases  at  about  the  end  of  the 
ninth  lustrum,  varying  much  according 
to  race  and  climate. 

Literature  of  '96-'97-'98. 

Series  of  250  cases  studied  as  regards 
the  age  at  which  menopause  takes  place. 
It  occurred  in  2  women  aged  37,  in  2 
aged  38,  3  at  39,  12  at  40,  3  at  41,  11  at 
42,  6  at  43,  and  8  at  44.  Beyond  the  nor- 
mal ages  the  change  came  on  in  3  pa- 
tients at  54,  and  in  the  same  number  at 
55,  and  in  1  at  56,  and  the  same  number 
in  patients  of  the  age  of  57,  58,  and  59, 
respectively.  Parviainen  ("Mith.  aus  der 
gynitk.  Klinik  der  Prof.  Engstein,"  vol. 
i,  Part  II,  '97). 

Cases  of  early  menopause  may  be  con- 
founded with  transitory  superinvolution 
of  the  uterus,  associated  with  amenor- 
rhcea  and  climacteric  signs  and  symp- 
toms. McCann  (Univ.  Med.  Mag.,  Mar., 
'98). 

The  disorders  of  the  menopause,  per 
se,  are  really  only  those  which  are  in 
some  way  connected  with  the  cessation 
of  menstruation,  and  they  are  compara- 
tively few  and  simple;  while  the  disor- 
ders and  symptoms  occurring  at  the 
period  of  the  change  of  life  or  grand 
climacteric  in  either  sex,  but  especially 
in  woman,  are  many  and  various,  and 
often  very  severe. 

Of  late  years  the  frequency  of  opera- 
tions for  the  removal  of  the  ovaries  has 
caused  the  subject  of  the  sudden  and 
artificial  menopause  thus  brought  about 
to  assume  great  importance,  and,  as  its 
symptoms  and  its  disorders  can  be 
studied  apart  from  the  symptoms  of  ad- 
vancing age  and  progressive  disease, 
much  valuable  light  has  been  thrown  on 
the  question  of  the  menopause  proper  by 
studying  the  history  of  the  symptoms 
following  the  post-operative  menopause. 


590 


MENOPAUSE,.  DISORDERS  OF.  SYMPTOMS. 


Among  the  afflictions  which  are  cus- 
tomarily  attributed  to  men6pause  are 
the  most-varied  nervous  manifestations, 
and  disturbances  of  temperament,  and 
even  of  mental  condition.  But  here, 
also,  it  is  necessary  to  discriminate  be- 
tween what  is  due  to  the  cessation  of 
menstruation,  and  all  the  woes  that 
begin  to  darken  the  life  of  so  many  mid- 
dle-aged women.  For,  at  this  period, 
some  women  are  profoundly  unhappy, 
and  not  without  reason.  Beauty  fades, 
they  grow  obese  and  gray,  and  feel  their 
age  in  all  their  social  relations.  Above 
all  there  is  the  feeling  that  there  is  no 
proper  sphere  of  activity  left  for  them. 
They  have  no  business,  as  men  have,  to 
occupy  their  attention.  A  woman  very 
probably  has  no  interests  which  really 
engross  her  and  give  her  an  aim  in  life. 
It  is,  indeed,  a  change  of  life;  but  it 
really  has  nothing  to  do  with  the  meno- 
pause. The  nervous  system  feels  the  in- 
fluence of  these  altered  conditions,  and 
despondency  continues  until  she  gets 
used  to  her  new  relations  with  her  sur- 
roundings and  acquires  new  interests. 

General  Symptoms. — The  disorders  of 
menopause  are  divisible  into  two  general 
classes,  which  are  subdivisible  into  sev- 
eral subclasses: — 

I.  Disorders  of  the   f  Flashes. 

circulation         }  Haemorrhages. 

f  Palpitations. 

II.  Disorders  of  the  J  Hystero-neuroses. 

nervous  system  1  Psychical  Dis- 
t  arbances. 

Besides  these,  it  is  necessary  to  recog- 
nize practically,  a  third  division: — 

III.  Complications,  or  disorders  inci- 
dent to  the  period  of  life  during  which 
the  menopause  occurs. 

Disorders  of  the  Circulation. — 
Flushes. — When  flashes,  or  flushes,  occur 
the  blood  rushes  suddenly  to  the  surface 


of  the  body,  particularly  to  the  face  and 
neck,  causing  a  violent  burning  and  ting- 
ling sensation  and  a  high  color,  followed 
in  a  few  minutes  by  a  free  and  distress- 
ing perspiration.  These  phenomena  are 
best  observed  in  vigorous  young  women 
from  whom  the  ovaries  have  been  re- 
moved, for  in  them  the  flashes  often 
come  on  within  two  or  three  weeks  of 
the  operation,  and  continue  for  several 
months,  or  even  for  over  a  year.  They 
may  recur  as  often  as  once  in  fifteen 
minutes,  but  generally  the  intervals  are 
somewhat  longer.  After  six  or  eight 
weeks  the  flashes  become  less  frequent, 
without  diminishing  much  in  violence, 
and  finally  they  diminish  both  in  fre- 
quency and  intensity,  until  they  cease  to 
recur. 

[The  following  description  of  her  sen- 
sations is  written  by  a  very  intelligent 
young  lady,  from  whom  the  tubes  and 
ovaries  were  removed  eighteen  mouth- 
previously,  for  a  small  fibroid  of  the 
uterus,  with  retroversion  and  incarcera- 
tion. The  tumor  in  the  uterus  has  di- 
minished in  size  during  the  interval  of 
time,  and  the  uterus  i>  held  in  proper 
position  by  ventrofixation. 

"I  am  afflicted  regularly  with  'Mashes' 
at  intervals  of  from  40  to  50  minutes 
day  and  night.  They  are  sometimes  pre- 
ceded by  slight  faintness  or  chill:  then, 
again,  with  dizzy  feeling,  or  slight  head- 
ache. I  can  almost  feel  myself  turning 
pale,  when  it  seems  that  the  blood  i- 
leaving  every  part  of  body:  so  noticeable 
is  it  that  just  previous  to  a  'Mash'  1  have 
been  asked  'Are  you  cold':'  'Are  you 
faint?'  or  'Are  you  ill?3 

"In  a  few  seconds,  however,  a  sort  of 
resigned  feeling  unconsciously  takes  pos- 
session of  me.  when  suddenly  a  wave  of 
heat  rushes  over  face.  arms,  and  uppei 
part  of  body,  face  and  hands  turn  a  mosi 
uncomfortable  red  color:  SOOD  the  heart 
beats  very  hard,  and  I  can  almo-t  hear 
it  thumping.  Soon  beads  of  moisture  be- 
gin to  stand  out  on  my  forehead,  chin, 
neck,  at  joining  of  lower  and  upper  arm-, 
and  on  bosom,  after  w  hich  the  heal  per- 


MENOPAUSE,  DISOEDEKS  OF.  SYMPTOMS. 


591 


meates  the  lower  part  of  body,  to  my 
toes. 

"When  a  'flash"  is  preceded  by  drowsi- 
ness, for  some  few  seconds  I  can  scarcely 
keep  my  eyes  open — seem  to  be  as  in  a 
dream,  and  arms  and  legs  feel  heavy. 
When  preceded  by  a  chill,  hands  and  feet 
feel  cold.  Always  before  'flash'  my  throat 
feels  parched,  and  I  am  very  thirsty. 
'Flashes'  seem  to  be  more  severe  after  a 
hearty  meal.*'    E.  W.  Gushing.] 

Ill  the  physiological  menopause  the 
same  flashes  are  observed,  although, 
usually,  they  are  much  less  violent;  they 
are  also  apt  to  last  rather  longer,  some- 
times for  two  years  or  more.  Although 
these  are  usually  classified  as  disturb- 
ances of  the  circulation,  they  are  prop- 
erly nervous  phenomena.  The  vascular 
system  merely  responds  to  the  stimulus 
which  causes  blushing  under  emotion, 
and  is  not  in  itself  disordered  at  all. 
The  whole  subject,  therefore,  might  be 
included  properly  under  the  disorders  of 
the  nervous  system. 

H ce  m  o  r  rh  a g  es.  —  Perhaps  the  same 
might  be  said  about  the  sudden  attacks 
of  haemorrhage  which  sometimes  occur 
at  about  the  time  of  the  menopause,  just 
as  they  do  at  puberty,  and,  indeed,  occa- 
sionally at  all  periods  of  the  sexual  life 
of  woman. 

So  many  cases  have  been  reported  that 
it  must  be  admitted  that  such  haemor- 
rhages really  occur  at  the  menopause, 
merely  as  a  result  of  vasomotor  disturb- 
ances, and  without  any  appreciable  dis- 
ease of  the  uterus. 

Nevertheless,  a  vigilant  and  painstak- 
ing skepticism  should  be  the  rule,  for 
usually  some  complication  will  be  found 
which  will  account  for  the  haemorrhages, 
especially  if  they  are  repeated  and  recur 
at  intervals  covering  a  considerable  space 
of  time.  The  apathy  and  credulity  with 
which  the  women  attribute  these  hemor- 
rhages to  the  change  of  life  are  only  the 
result  of  the  false  teaching  of  the  pro- 


fession at  times  when  the  pathology  of 
uterine  diseases  was  not  understood. 
Many  a  valuable  life  is  lost  because  flow 
at  this  time  is  attributed  to  the  climac- 
teric, when  really  there  is  grave  organic- 
disease  present  and  progressing. 

Not  infrequently  the  climacteric  is  pre- 
ceded by  two  or  three  periods  of  excessive 
flow  of  blood  without  any  special  local 
pathological  change.  A.  R.  Simpson 
(Clinical  Jour.,  July  18,  '94). 

Literature  of  '96-'97-'98. 

Climacteric  haemorrhages  are  due  to 
arterial  sclerosis.  Eeinicke  (Arch.  f. 
Gynak.,  B.  52,  H.  2,  '97;. 

Disorders  of  the  Xervous  System. 
— "Palpitations."  —  The  symptoms  of 
"palpitation  of  the  heart"  and  of  attacks 
of  syncope  from  which  women  suffer  at 
the  time  of  the  climacteric  are  quite 
similar  both  in  kind  and  degree  to 
those  with  which  a  certain  proportion 
of  women  of  all  ages  are  troubled.  The 
only  feature  peculiar  to  the  change  of 
life  is  that  women  often  present  these 
symptoms  at  that  period  who  have  not 
been  troubled  in  this  way  during  their 
previous  years,  and  who  certainly  have 
no  organic  lesion  of  the  heart.  Like  the 
flushing  and  the  uterine  haemorrhages 
mentioned  above,  these  symptoms  are  to 
be  understood  as  disturbances  of  regula- 
tion, not  as  diseases. 

Tachycardia  in  women  is  most  often 
seen  during  the  menopause.    Those  who 
pass  through  the  change  early  are  more 
liable  to  it  than  those  who  menstruate 
until  later  in  life.    It  occurs  with  special 
frequency  when  the  menopause  has  been 
prematurely  induced  by  surgical  opera- 
tion or  disease.   Baldwin  (Brooklyn  Med. 
Jour.,  Nov..  '95). 
IT  y  s  f  r  r  o-disturbances   and  Psych  ica  I 
Disturbances. — These  phenomena  do  not 
differ  at  all   from  those  which  affect 
nervous  and  hysterical  women  at  other 
periods  of  their  lives,  the  only  peculiarity 
is  that  they  sometimes  attack  women 


592 


MENOPAUSE,  DISORDERS  OF.  SYMPTOMS. 


who  have  always  been  free  from  such 
troubles. 

It  will  not,  therefore,  be  necessary  to 
describe  the  various  symptoms  and  varie- 
ties of  hysterical  and  hysterico-neurotic 
disturbances,  the  alterations  in  temper 
and  temperament,  ranging  all  the  way 
from  caprice  to  melancholy,  which  may 
affect  women  at  this  change  of  their 
lives.  What  is  desirable  to  know  is  why 
these  disturbances  should  affect  some 
women  at  this  time  and  not  others,  and 
whether  anything  can  be  done  to  relieve 
them. 

It  is  quite  evident  that  at  the  meno- 
pause we  have  to  do  with  two  processes: 

(1)  the  cessation  of  function  of  the  ova- 
ries and  of  the  menstruation,  which  is 
the  accompaniment  of  such  function; 

(2)  the  involution  of  the  uterus,  which 
goes  on,  or  should  go  on,  pari  passu  with 
the  diminution  of  ovarian  activity.  The 
histories  of  women  who  suffer  from  hys- 
terical and  nervous  disorders  at  the 
menopause,  and  those  of  women  who 
suffer  from  hyperinvolution  or  from 
originally  insufficient  development  of 
the  uterus  are  very  similar,  and  careful 
study  of  individual  cases  has  led  me  to 
believe  that  the  disturbances  of  the 
former  are  largely  due  to  want  of  proper 
relation  in  time  or  in  amount  between 
the  diminution  of  functional  activity  and 
the  involution  of  the  ovaries  and  of  the 
uterus,  respectively. 

When  the  function  of  the  ovaries 
ceases  too  suddenly  for  the  uterus,  or 
when  —  owing  to  congestion,  endome- 
tritis, polypi,  small  fibroids,  or  other 
causes — the  uterus  cannot  undergo  in- 
volution concurrently  with  the  ovary, 
flashes  and  hemorrhages  follow,  com- 
plicated with  the  general  train  of  symp- 
toms witnessed  after  surgical  removal  of 
the  ovaries. 

When,  on  the  other  hand,  the  uterus 


tends  to  cease  its  functions  sooner  than 
the  ovary,  stimulation  originating  from 
the  latter  to  continue  menstruation  gives 
rise  to  a  set  of  symptoms  similar  to  those 
witnessed  in  cases  of  hyperinvolution  of 
the  uterus  after  childbed  or  prolonged 
lactation  or  exhausting  diseases;  or  in 
cases  of  undeveloped  uterus,  where  after 
puberty  the  infantile  condition  of  that 
organ  remains,  while  the  ovaries  develop 
fully. 

Atresia  of  the  uterus  after  the  meno- 
pause occurs  pathologically  much  more 
frequently  than  is  supposed.  The  atresia 
is  physiological  only  after  complete 
atrophy  of  the  body  of  the  uterus  and 
its  endometrium.  The  symptoms  of  the 
condition  mislead  by  directing  attention 
to  the  nervous  system  more  particularly 
than  to  the  true  seat  of  disease.  H.  L.  E. 
Johnson  (Jour.  Amer.  Med.  Assoc.,  Dec. 
7,  '95). 

Literature  of  '96-'97-'98. 

At  the  period  of  the  menopause  the 
vulva  is  apt  to  become  affected  with 
local  hyperesthesia,  which  is  a  symptom 
of  many  conditions.  It  may  be  due  to  a 
pure  neurosis;  to  reflex  cause,  such  as 
early  carcinoma  cervicis;  to  mucous 
polypus  or  prolapsed  ovary:  or  to  krau- 
rosis, local  rashes,  dirt,  parasites,  vaginal 
or  uterine  discharges;  irritating  urine, 
as  in  cases  of  acidity,  gout,  or  diabetes. 
Amand  Routh  (West  London  Medico- 
Chir.  Soc:  Univ.  Med.  Jour..  Mar.,  '97). 

Neuroses  seen  at  the  time  of  the  meno- 
pause show  many  gradations  from  nerv- 
ous irritability  with  effects  on  the  char- 
acter and  temper  to  fully-developed  in- 
sanity, which  has  a  tendency  in  a  large 
proportion  of  cases  to  melancholia,  a  de- 
lusional insanity,  less  frequently  to 
mental  weakness,  and  rarely  to  general 
paralysis.  The  change  in  the  reproduc- 
tive organs  leads  in  some  to  a  morbid 
querulousness.  in  others  to  a  jealousy. 
Sexual  excitement  sometimes  is  developed 
which  exceeds  all  control,  depraved  and 
vicious  habits  may  show  themselves,  and 
dangerous  accusations  be  made.  Drunk- 
enness and  the  drug-habit  are  espeeially 
noted  at  the  climacteric.    Charles  Luke 


MENOPAUSE,  DISORDERS  OF. 


SYMPTOMS.  COMPLICATIONS. 


593 


(West  London  Medico-Chir.  Soc;  Univ. 
Med.  Jour.,  Mar.,  '97). 

Attention  called  to  dyspareunia  at  this 
period.  Cases  occur  where  the  introitus 
is  small;  the  mucous  membrane  of  the 
vulva  has  already  acquired  that  smooth 
and  glazed  appearance  characteristic  of 
senility,  and  around  the  ostium  vaginae 
are  certain  red,  well-defined  circumscribed 
spots,  extending  forward  and  involving 
the  meatus  urinarius  and  the  urethral 
canal.  These  are  exquisitely  tender  and 
bathed  in  a  muco-purulent  discharge. 
Mansell-Moullin  (West  London  Medico- 
Chir.  Soc;  Univ.  Med.  Jour.,  Mar.,  '97). 

While  the  cilia  of  the  uterine  and  cer- 
vical epithelium  grow  scanty  in  sickly 
women  near  the  menopause,  they  some- 
times remain  perfect  in  women  over  60 
where  the  uterine  muscular  tissue  has 
undergone  degenerative  changes  percep- 
tible to  the  naked  eye.  Parviainen 
("Mith.  aus  der  gynak.  Klinik  der  Prof. 
Engstein,"  vol.  i,  Part  II,  '97). 

Headache,  nervousness,  hysterical 
manifestations  of  all  kinds,  depression  of 
spirits,  change  of  temperament  always 
for  the  worse,  even  real  melancholy  and 
insanity;  such  are  the  woes  which  are 
added  to  the  unpleasant  conditions  in- 
separable from  this  age,  and  referred  to 
in  the  beginning  of  this  article. 

Attention  called  to  the  very  intimate 
relation  which  exists  between  the  meno- 
pause and  the  pathological  conditions  of 
the  uterus  and  exophthalmic  goitre.  In 
this  relationship  the  latter  is  placed  in 
the  position  of  an  effect  or  consequence, 
and  not  the  cause,  of  the  uterine  condi- 
tion. An  improvement  in  the  local  con- 
dition is  always  followed  by  the  appear- 
ance of  the  general  disease.  Jouin  (Nouv. 
Arch.  d'Obstet.  et  de  Gynec,  No.  6,  '95). 

Sensory  throat-neuroses  are  common 
at  the  menopause.  The  sensations  of 
which  these  patients  complain  vary 
enormously  in  kind  and  in  intensity,  but 
can  all  be  summarized  under  the  two 
large  headings  of  paresthesia  and  of  neu- 
ralgia, the  former  being  by  far  the  more 
frequent  one.  In  the  very  worst  eases, 
which  are  rare,  the  suffering  appears  to 
be  extreme  and  the  mental  condition  of 


the  patient  deplorable.  In  a  large  num- 
ber of  cases  the  throat-symptoms  com- 
plained of  are  the  only  sign  of  the  ap- 
proaching change  of  life,  and  sometimes 
even  precede  the  menstrual  irregularities. 
In  another  perhaps  equally  large  num- 
ber they  either  follow  the  usual  uterine 
disturbances  of  the  climacteric  period  or 
are  associated  with  other  complications 
of  the  menopause.  In  a  very  large  num- 
ber the  appearances  are  quite  normal ;  in 
other  cases,  when  in  women  during  the 
climacteric  period,  a  few  small  pharyn- 
geal granulations  or  a  very  slight  en- 
largement of  the  lingual  tonsil  or  some 
hardly  noticeable  thickening  of  the 
lateral  folds  of  the  pharynx  are  detected. 
Felix  Semon  (Brit.  Med.  Jour.,  Jan.  5, 
'95). 

Literature  of  '96-'97-'98. 

Investigation  of  one  hundred  cases  of 
insanity  occurring  during  menopause. 
The  forms  were  present  as  follows:  Mel- 
ancholia in  67  per  cent.;  mania,  24  per 
cent.;-  dementia,  4  per  cent.;  epileptic 
insanity,  3  per  cent.;  general  paralysis, 
2  per  cent.  The  prognosis  is  usually 
favorable,  40  per  cent,  recovering.  The 
duration  of  the  attack  varies  from  three 
months  to  three  years,  after  which  time 
the  outlook  is  hopeless.  Henry  Suther- 
land (Univ.  Med.  Jour.,  Mar.,  '97). 

Complications . — The  complications 
or  diseases  incident  to  the  time  of  life 
at  which  the  menopause  occurs  are,  in 
reality,  the  factors  that  have  caused  the 
change  of  life  to  be  dreaded  and  to  be 
looked  upon  as  a  serious  crisis. 

In  all  cases  in  which  a  patient  comes 
under  the  care  of  the  physician  at  this 
age,  perhaps  more  than  at  others,  it  is 
important  to  ascertain  that  the  heart 
and  kidneys  are  free  from  organic  dis- 
ease. This  is  the  period  when  these 
organs  are  apt  to  fail,  in  either  sex. 

Literature  of  '96-'97-'98. 

Attention  called  to  the  frequency  of 
utero-ovarian  irritation  at  the  time  of 
the  menopause  as  a  factor  in  the  causa- 

•38 


594 


MENOPAUSE,  DISORDERS  OF.  COMPLICATIONS. 


tion  of  rheumatoid  arthritis.  W.  Arm- 
strong (Brit.  Gyn.  Jour.,  xliv,  496,  '96). 

Following  the  cessation  of  the  meno- 
pause the  modification  of  the  menstrual 
flow  can  cause  a  congestion  of  the  kid- 
neys, varying  in  its  intensity.  The  symp- 
toms observed  have  been  oliguria,  albu- 
minuria, and  hematuria,  often  accom- 
panied with  lumbar  pains,  nausea,  and 
headache.  Local  bleeding  and  mild  di- 
uretics recommended.  Le  Gendre  (Med- 
ico-Surg.  Bull.,  July  25,  '98). 

Of  the  diseases  more  closely  connected 
with  the  genital  system,  first  in  impor- 
tance, first  in  gravity,  and  most  serions 
if  neglected,  is  cancer  of  the  uterus  or 
of  the  vagina.  In  all  cases  of  undue  or 
irregular  bleeding  from  the  genital  tract 
it  is  imperative  to  make  a  thorough 
local  examination,  since  in  a  large  pro- 
portion of  cases  the  cause  will  be  found 
to  be  a  cancer.  In  this  matter  the 
knowledge  and  care  of  this  generation 
of  physicians  must  undo  the  mischief 
that  has  been  wrought  by  the  false  teach- 
ing of  previous  generations,  that  irregu- 
lar haemorrhages  were  natural  to  the 
change  of  life.  The  truth  is  that  the 
menopause  is  an  evil  period,  when  can- 
cers are  liable  to  develop. 

"Ulceration  of  the  uterus"  was  also — 
and  is  still — too  often  diagnosticated  in 
cases  of  uterine  cancer  attended  by  in- 
tractable bleeding  and  only  recognized 
when  the  disease  is  far  advanced  and  the 
patients  have  lost  their  only  chance  of 
rescue. 

Certain  axioms  should  guide  the  mod- 
prn  practitioner  in  this  connection: — 

1.  All  irregular  or  profuse  haemor- 
rhages about  the  period  of  the  change 
of  life  are  suspicious;  they  therefore  re- 
quire immediate,  thorough,  and  com- 
petent examination. 

Analysis  of  the  complications  of  meno- 
pause in  500  women.  Out  of  this  num- 
ber, the  flow  of  blood  returned  a  year  or 
more,  after  the  menopause  had  become 
established,  in  183  cases.    Of  these  over 


one-half,  or  54  per  cent.,  were  found  to 
be  suffering  from  uterine  cancer.  Neu- 
mann (Monats.  f.  Geburts.  und  Gynak., 
B.  1,  H.  2,  '95). 

Literature  of  '96-'97-'98. 

Diagnosis  between  benign  and  malig- 
nant bleeding  after  menopause.  Menor- 
rhagia of  the  menopause  appears  as  a 
sudden  and  very  free  discharge  of  blood 
following  distinct  cessation  of  the  cata- 
menia  for  two  or  three  months.  The  dis- 
charge occasionally  recurs.  The  bleeding 
of  cancer  is  insidious,  irregular  in  char- 
acter, and  very  frequently  appears  in  the 
interval  of  the  period  during  the  last 
year  or  two  of  menstruation.  Doleris 
(Bull,  et  Mem.  de  la  Soc.  Obstet.,  etc., 
Paris,  No.  7,  '97). 

2.  All  cases  of  incipient  cancer  of  the 
uterus  are  easily  diagnosticated  by  care- 
ful examination,  aided  by  the  curette 
and  microscope  in  doubtful  cases,  but 
usually  by  the  presence  and  character 
of  an  ulcer. 

3.  All  cases  of  cancer  of  the  uterus  in 
the  early  stages  are  susceptible  of  com- 
plete removal  by  total  hysterectomy, 
with  less  than  2  per  cent,  of  mortality 
in  competent  hands.  There  is,  in  fact, 
no  organ  of  the  body  where  cancer  can 
be  so  totally  and  widely  removed  as  in 
cancer  of  the  uterus. 

4.  A  large  proportion,  probably  a  large 
majority,  of  cases  in  which  total  extirpa- 
tion of  the  uterus,  for  cancer,  is  per- 
formed quite  early,  never  have  relapse 
or  recurrence  in  the  scar  or  elsewhere, 
and  they  enjoy,  not  only  life,  but  the 
best  of  health. 

Next  in  frequency,  after  cancer,  when 
haemorrhage  occurs  after  menopause  are 
intra-uterine  or  intramural  fibroids. 
There  may  also  be  polypoid  growths  in 
the  uterine  cavity  of  the  ordinary  mu- 
cous and  glandular  type.  All  these  may 
give  rise  to  frequent  haemorrhages  that 
tend  greatly  to  reduce  the  strength  of 
the  patient. 


MENOPAUSE,  DISORDERS  OF. 


TREATMENT. 


595 


[I  have  repeatedly  removed  such 
growths  from  women  between  45  and  55 
years,  who  had  suffered  from  profuse 
flowing  for  long  periods  under  the  im- 
pression that  it  was  a  natural  accompani- 
ment of  the  change  of  life,  and  that  noth- 
ing could  or  should  be  done  to  relieve  it. 
E.  W.  Gushing.] 

The  tendency  to  obesity  after  meno- 
pause may  cause  neoplasms  of  the  geni- 
tal system  to  be  overlooked.  The  follow- 
ing are  the  disorders  at  all  likely  to  be 
confused  with  fat-accumulation  after 
menopause:  lipomata,  dermoids,  fibroids, 
tumors  of  abdominal  Avail,  encysted  peri- 
tonitis, hydatids  of  peritoneum,  "ovarian 
tumors."  Manton  (Med.  Age,  July  25, 
'95). 

Case  in  which  a  large  unilocular  blood- 
cyst  developed  in  the  wall  of  the  uterus 
after  menopause.  J.  C.  Webster  (Amer. 
Jour.  Med.  Sci.,  Mar.,  '95). 

Literature  of  '96-'97-'98. 

The  menopause  has  very  little,  if  any, 
influence  in  arresting  the  growth  of  uter- 
ine fibromata  in  a  large  number  of  cases; 
indeed,  many  examples  of  their  rapid  in- 
creased growth  have  occurred.  One  of  the 
strongest  indications  for  hysterectomy 
after  the  menopause  is  the  tendency  of 
the  tumor  to  undergo  some  form  of  de- 
generation which,  of  itself,  may  prove 
fatal.  Hysterectomy  after  the  menopause 
should  be  resorted  to  whenever  the 
usually-accepted  symptoms  present  them- 
selves which  are  acknowledged  to  be  of 
sufficient  gravity  to  require  that  opera- 
tion in  any  other  period  of  life.  J.  T. 
Johnson  (Med.  Review,  May,  '98). 

An  erroneous  idea  prevails  that  the 
pathological  history  of  fibroids  termi- 
nates with  the  establishment  of  the 
climacteric.  On  the  contrary,  it  may 
only  begin  at  that  time.  Picque  (La 
Gynoc,  Apr.  15,  '98). 

Of  special  importance  is  the  condition 
of  adenoma  of  the  uterus,  which  attacks 
women  of  this  age,  often  after  they  have 
ceased  to  menstruate  entirely.  Coming 
on  with  the  symptoms  of  a  simple  hy- 
pertrophic endometritis,  it  is,  perhaps, 
treated   by  curetting,   and  apparently 


cured  for  some  months,  when  the  haemor- 
rhages commence  again,  and  unless  hys- 
terectomy is  performed  the  disease  grad- 
ually, but  inevitably,  passes  into  cancer 
of  the  body  of  the  uterus.  The  diag- 
nosis is  easily  made  on  the  first  curette- 
ment,  by  the  abundance  and  the  micro- 
scopical character  of  the  pieces  of  tissue 
which  are  removed.  As  soon  as  the  diag- 
nosis is  certified  hysterectomy  should  be 
performed. 

Simple  endometritis,  with  more  or  less 
thickening  of  the  mucous  membrane,  is 
very  frequent  at  the  time  of  the  meno- 
pause; it  tends  to  delay  the  cessation  of 
the  menses,  especially  if  there  is  any 
polypoid  formation,  as  above  mentioned. 

In  some  cases  the  menstruation  either 
ceases  or  is  very  scanty,  and  the  meno- 
pause thus  occurring  is  accompanied 
with  nervous  symptoms,  hot  flashes,  or 
even  severe  hystero-neuroses.  A  local 
examination  is  also  important,  since 
some  uterine  trouble  will  generally  be 
found  to  account  for  the  symptoms.  In 
some  cases  the  uterus  is  retroverted, 
heavy,  and  sensitive;  in  others  it  is  ap- 
parently normal  in  size  and  position,  but 
it  is  tender  on  pressure,  and  if  a  sound 
is  passed  into  it  the  endometrium  of  the 
fundus  is  found  to  be  extremely  sensi- 
tive and  perhaps  thickened. 

Treatment. — In  regard  to  the  nervous 
symptoms,  great  caution  should  be  used 
not  to  commence  a  course  of  treatment 
with  narcotics,  which  is  apt  to  have  dis- 
astrous consequences.  Morphine,  co- 
caine, and  other  habits  are  easily  con- 
tracted by  these  cases.  If  all  local  dis- 
orders are  properly  diagnosticated  and 
treated,  and  nervous  symptoms  still  exist, 
attention  should  be  paid  to  the  general 
condition.  A  kindly  word  and  a  little 
consolation  will  often  go  farther  than 
medicine  in  alleviating  the  nervous  man- 
I  ifestations.    When  the  circumstances  of 


596 


MENOPAUSE,  DISORDERS  OF.  TREATMENT. 


the  patient  permit  it,  change  of  scene, 
particularly  foreign  travel,  is  of  the 
greatest  advantage.  Anything  that  will 
give  the  woman  an  interest  in  life  and 
take  her  thoughts  off  herself  is  distinctly 
beneficial. 

Simple  endometritis  with  more  or  less 
thickening  is  easily  cured  by  curettement 
and  application  of  strong  solution  of 
iodine  and  carbolic  acid,  or  of  peroxide 
of  hydrogen,  to  the  uterine  cavity.  At 
the  same  time  any  raw  surfaces  at  the 
angles  of  the  os  uteri,  the  result  of  old 
laceration,  should  be  carefully  repaired, 
for  it  is  precisely  in  these  neglected 
lacerations  that  cancer  is  so  prone  to 
develop. 

Curettage  of  the  cavity  of  the  uterus 
in  fibroids  where  the  chief  symptoms  are 
menorrhagia  and  metrorrhagia  is  useful 
in  three  classes  of  cases,  viz.:  — 

1.  In  cases  suitable  for  operation;  but 
when  the  patients  are  debilitated  by  loss 
of  blood  the  procedure  affords  a  period 
of  rest  and  freedom  from  haemorrhage, 
which  allows  of  recuperation  before  the 
major  operation. 

2.  In  cases  of  small  fibroids  which  do 
not  cause  pain. 

3.  In  cases  in  which  the  menopause  is 
approaching. 

In  the  latter  class  the  operation  may 
have  to  be  repeated  several  times.  Orloff 
(Med.  Chronicle,  Aug.,  '94). 

In  cases  in  which  there  is  retroversion 
or  the  endometrium  of  the  fundus  is 
found  thickened  and  extremely  sensitive, 
appropriate  treatment,  by  replacement 
and  support,  if  necessary,  and  by  dilata- 
tion of  the  cervix,  and  applications  of 
carbolic  acid  or  peroxide  of  hydrogen  to 
the  endometrium,  will  usually  have  the 
happiest  results. 

The  haemorrhages  are  sometimes  suf- 
ficiently severe  to  demand  active  treat- 
ment, -even  when  no  local  lesions  arc  to 
be  discerned. 

Haemorrhage  is  of  the  first  importance 
in  the  climacteric.    Purgatives  should  be 


employed,  particularly  against  the  hyper- 
aemic  disturbances  and  collateral  con- 
gestion which  give  rise  to  the  complex 
symptoms  of  abdominal  plethora.  Xo 
drastic  purgative,  however,  should  be 
used,  but  only  such  as  exercise  a  gradual 
and  continued  influence  upon  intestinal 
activity,  such  as  pulp  of  prunes,  tama- 
rinds, manna,  rhubarb,  and  the  moderate 
salts.  Enemas  and  intestinal  irrigation 
are  also  of  value,  with  dietetic  and  hy- 
gienic measures,  Glauber  salts,  and  pot- 
ash-salt waters.  In  severe  haemorrhage 
rest  and  cold-water  injections  are  indi- 
cated, with  the  addition  of  aqua  ferridi, 
sus  aqua  chloridi  (15  to  250).  If  the 
flooding  does  not  cease,  the  vagina  should 
be  tamponed  with  iodoform  gauze,  and 
ergot  given  internally,  20  drops  every 
hour  or  two.  Kisch  (Med.  Xeuigkeiten 
f.  prak.  Aerzte,  Apr.  8,  '93). 

In  the  haemorrhages  of  the  menopause 
hydrastinine  is  preferable  to  hydrastis. 
Porak  (Bull,  de  la  Soc.  de  Med.  Prat., 
Mar.  15,  '92). 

Cycling  may  have  an  injurious  effect 
on  women  at  the  time  of  the  menopause, 
and  should  not  be  indulged  in  except  on 
the  advice  of  a  physician,  especially  if 
the  patient  is  anaemic  and  has  functional 
cardiac  trouble.  H.  Macnaughton  Jones 
(Med.  Press,  Nov.  4,  '95). 

Literature  of  'dQ-'dl-^S. 

In  climacteric  haemorrhages  rest,  strict 
regulation  of  diet,  with  the  avoidance  of 
alcohol,  strong  tea  and  coffee,  and  the 
use  of  laxatives  are  sufficient  in  mild 
cases.  Dilatation  of  the  cervical  canal 
and  intra-nterine  applications  of  Mon- 
sell's  solution  are  preferable  to  curette- 
ment. In  obstinate  cases  in  which  the 
patient  is  really  in  danger  from  repeated 
haemorrhages  total  extirpation  is  indi- 
cated, the  results  being  quite  satisfac- 
tory, while  the  mortality  is  only  a  little 
over  1  per  cent.  Keinicke  (Archiv  fur 
Cyniik..  B.  52,  11.  2.  "97). 

The  treatment  of  the  various  symp- 
toms occurring  in  the  course  of  the 
menopause  does  not  differ  from  that  of 
tin1  same  phenomena  as  witnessed  in 


MENOPAUSE,  DISORDERS  OF. 


MENTHA. 


597 


various  diseases.  Hence  symptomatic 
treatment  meets  all  indications. 

In  the  treatment  of  pruritus  of  the 
vulva  or  vagina,  so  often  a  complication 
of  the  menopause,  the  patient  should  be 
given  a  lukewarm  bath  (88°  F.)  before  go- 
ing to  sleep,  with  the  addition  of  2  pounds 
of  wheat-bran,  placed  in  a  linen  sack  in 
the  bath.  After  the  bath  the  vulva  and 
surrounding  parts  are  dusted  with  the 
following  powder:  Salicylic  acid,  1  part; 
starch  and  talcum,  of  each,  50  parts; 
mixed  and  used  as  a  dusting-powder, 
several  times  daily.  Of  special  signifi- 
cance in  the  climacteric  is  the  diet.  Kisch 
(Med.  Neuigkeiten  f.  prak.  Aerzte,  Apr. 
8,  '93). 

'  Ovarian  therapy  in  the  treatment  of 
the  phenomena  of  the  menopause  has 
been  reported  with  more  or  less  success. 
It  consists  in  the  administration  of  the 
ovary  in  its  natural  condition,  ovarian 
powder  obtained  by  desiccation,  or  a 
glycerin-extract.  The  remedy  may  be 
given  in  2-grain  doses  before  meals.  It 
is  usually  best  to  begin  with  one  dose 
before  the  noon  meals.  The  remedy  is 
credited  by  various  clinicians  with  the 
power  of  arresting  the  untoward  effects 
during  the  climacteric  or  preventing 
them  when  the  menopause  first  manifests 
itself. 

Literature  of  '96-'97-'98. 

Ovarian  extract  given  in  twelve  cases 
with  the  best  results.  The  patients  suf- 
fered from  the  usual  nervous  condition, 
the  result  of  oophorectomy  or  normal 
menopause.  No  disagreeable  effects  from 
the  exhibition  of  the  drug  in  tabloids, 
and  no  constitutional  disturbance  were 
noted.  Improvement  in  the  symptoms 
began  after  the  lapse  of  about  forty- 
eight  hours,  and  cure  was  complete 
within  a  month.  Mond  (Munch,  med. 
Woch.,  No.  30,  '90). 

Successful  treatment  by  fresh  ovarian 
tissue  of  climacteric  disturbances  follow- 
ing castration.  The  dose  was  77  grains 
twice  a  day,  gradually  increased  to  310 
grains,  the  general  condition  of  the  pa- 


tient and  the  character  of  the  urine  be- 
ing watched  carefully.  The  treatment 
was  continued  for  eighteen  days,  before 
which  time  any  temporary  stoppage  of 
the  drug  was  followed  by  an  increase  in 
frequency  of  the  attacks  of  dizziness, 
flushing,  and  palpitation.  After  the 
eighteenth  day  the  stoppage  did  not 
cause  any  trouble,  and  the  patient  was 
discharged  suffering  from  only  four  or 
five  light  attacks  daily  that  did  not  cause 
her  any  inconvenience.  F.  Mainzer 
(Deut.  med.  Woch.,  Mar.  19,  '90). 

In  seven  cases  in  which  there  were  se- 
vere symptoms  during  the  natural  meno- 
pause pastilles  made  from  the  dry  ovarian 
substance  (cow),  each  pastille  containing 
3  grains,  were  successfully  employed. 
Chrobak  (Centralb.  f.  Gynak.,  No.  20, 
'90). 

Ovarian  tablets  possess  the  power  of 
modifying  the  unpleasant  phenomena  of 
the  climacteric,  whether  physiological  or 
anticipated,  without  producing  evil  ef- 
fects. Landau  (Berliner  klin.  Woch.,  No. 
25,  '90). 

By  use  of  ovarian  extract  disagreeable 
symptoms  of  the  natural  menopause  are 
relieved  or  disappear.  It  rapidly  over- 
comes the  metrorrhagia  of  the  meno- 
pause not  connected  with  new  growTths. 
Results  of  treatment  are  usually  ap- 
parent on  the  second  or  third  day. 
Preparations  in  wine  preferred,  daily 
dosage  being  5  drachms,  containing  3 
grains  of  ovarian  extract.  Jacobs  (Dub- 
lin Jour.  Med.  Sci.,  Sept.  1,  '97). 

Oophorin  preparations  given  to  women 
suffering  from  acne  rosacea  and  cutane- 
ous disorders  at  the  menopause,  with 
satisfactory  results.  E.  Saalfeld  (Ber- 
liner klin.  Woch.,  No.  13,  '98).  (See  also 
Animal  Exteacts,  in  volume  i.) 

Ernest  W.  Cushing, 

Boston. 

MENORRHAGIA.    See  Uterus. 

MENTHA. — Two  varieties  of  mentha, 
mentha  piperita  and  mentha  viridis  are 
employed  in  medicine. 

Mentha  Piperita. 

Mentha  piperita,  or  peppermint,  is  the 
leaves  and  tops  of  Mentha  pi  peril  a  (order 


598  MENTHA. 

Labiatce):  a  plant  indigenous  to  Great 
Britain,  but  naturalized  in  the  United 
States  and  many  other  countries.  It 
has  an  aromatic  odor  and  taste,  and  con- 
tains a  volatile  oil,  from  which  is  ob- 
tained menthol,  the  so-called  pepper- 
mint-camphor. The  oil  of  peppermint 
is  soluble  in  alcohol,  ether,  and  chloro- 
form. 

Preparations  and  Doses. — Aqua  men- 
tha? piperita?,  1/2  to  2  ounces. 

Oleum  mentha?  piperita?,  1  to  5  min- 
ims. 

Spiritus  mentha?  piperita?,  10  to  30 
minims.  . 

Trochesci  mentha?  piperita?  (V6  minim 
of  oil),  1  to  5  troches. 

Therapeutics.  —  The  bruised  fresh 
leaves,  or  the  fresh  leaves  made  into  a 
poultice,  are  useful  domestic  remedies  for 
the  relief  of  colic,  sick  headache,  nausea, 
and  painful  affections  (colic,  rheumatism, 
etc.).  Peppermint-water  is  used  as  a 
flavoring  to  cover  the  taste  of  nauseous 
medicine,  and  as  an  antispasmodic  to 
lessen  the  griping  effect  of  certain  reme- 
dies. It  is  a  popular  remedy  for  colic  and 
flatulence  in  infants,  especially  when 
combined  with  a  small  dose  of  bicarbo- 
nate of  soda  (soda-mint).  The  spirit  and 
troches  may  be  used  for  the  same  pur- 
poses in  adults.  The  oil  has  analytic 
properties,  and  may  be  painted  over  the 
course  of  the  nerves,  in  neuralgia,  and 
over  the  painful  joints  in  arthralgia. 
Evaporation  should  be  prevented  by  cov- 
ering with  oiled  muslin.  It  is  also  use- 
ful in  myalgia  and  chronic  gout. 

In  toothache  a  pledget  of  cotton,  wet 
with  the  oil  and  inserted  into  the  cavity, 
will  give  relief,  acting  both  as  an  anti- 
septic and  an  analgesic. 

The  troches  are  useful  to  disguise  the 
breath,  or  as  a  carminative  and  stimulat- 
ing stomachic. 

In  acute  rheumatism  the  oil  may  be 


MENTHOL. 

I  applied  to  the  painful  joints  and  covered 
with  cotton  and  oiled  muslin. 

Inhalations  of  the  oil  have  been  rec- 
ommended in  pulmonary  tuberculosis, 
but  clinical  experience  seems  to  show 
that  its  value  is  slight. 

Mentha  Virides. 

Mentha  virides,  or  spearmint,  is  the 
leaves  and  tops  of  Mentha  virides.  It  is 
a  widely-distributed  variety  of  mint,  pos- 
sessing properties  similar  to  those  of  pep- 
permint, but,  being  less  powerful,  is 
often  preferred  for  children.  The  active 
principle  is  a  volatile  oil. 

Preparations  and  Doses. — Aqua  men- 
tha  virides,  1/2  to  2  ounces. 

Oleum  mentha  virides,  1  to  5  minims. 

Spiritus  mentha  virides,  15  to  10 
minims. 

Therapeutics.  —  The  preparations  of 
spearmint  are  used  in  the  same  manner 
and  doses  as  those  of  peppermint.  Their 
taste,  is,  perhaps,  less  agreeable,  but  they 
are  often  found  to  be  more  acceptable  to 
the  stomach.  Several  other  species  of 
mint  are  used  in  medicine,  though  non- 
official.  These  have  properties  similar 
to  those  of  peppermint  and  spearmint. 

C.   SUMXER  "WlTHERSTIXE, 

Philadelphia. 

MENTHOL. — Menthol  is  the  stearop- 
ten  from  the  essential  oil  of  Mentha 
piperita.  It  occurs  in  colorless  crystals, 
having  a  strong  peppermint  odor.  It  is 
soluble  in  alcohol,  ether,  bisulphide  of 
carbon,  oils,  and  acetic  acid,  and  is  very 
slightly  soluble  in  water.  It  melts  at 
110°  F.  It  may  be  fused  or  compressed 
into  cones  or  pencils.  Chinese  and 
Japanese  oils  of  peppermint  are  richer 
in  menthol  than  the  official  oil.  Men- 
thiodol  is  a  mixture  of  -1  parts  of  men- 
thol and  1  part  of  iodol,  usually  molded 
into  cones  or  pencils,  and  used  the  same 
I  as  menthol.    Menthophenol  is  obtained 


MENTHOL.  THERAPEUTICS. 


599 


by  mixing  1  part  of  phenol  and  3  parts 
of  menthol,  and  then  melting  the  mixt- 
ure; it  is  antiseptic  and  analgesic. 

Physiological  Action. — Menthol  in  the 
frog  paralyzes  the  spinal  centres,  then 
the  nerve-trunks;  small  doses  excite, 
while  large  doses  paralyze,  the  heart  and 
cause  the  respiration  to  become  shallow 
and  slow.  There  is  irregular  reduction 
of  blood-pressure  and  loss  of  sensibility, 
the  animal  growing  quite  cold.  Binet  re- 
cently showed  that  menthol  was  not 
eliminated  by  the  lungs,  as  was  at  one 
time  believed  to  be  the  case. 

The  sensation  of  cold  produced  by 
menthol  when  applied  locally  was  shown 
by  Goldscheider  not  to  be  due  to  actual 
lowering  of  the  temperature  of  the  sur- 
face. In  fact,  the  application  of  a  solu- 
tion of  menthol  he  found  to  be  followed 
by  a  rise  of  2°  C.  He,  therefore,  at- 
tributes the  sensation  to  the  influence  of 
the  drug  upon  the  peripheral  nerves  of 
sensation:  an  action  quite  independent, 
also,  of  evaporation. 

Therapeutics.  —  Gastro  -  Intestinal 
Disorders. — Menthol  may  be  given  in 
doses  of  3  to  5  grains  in  capsules  for  the 
relief  of  nervous  dyspepsia  and  diarrhoea. 
It  has  also  been  used  in  the  dose  of  1 
or  2  grains  as  a  sedative  in  gastralgia. 
It  is,  however,  contra-indicated  if  there 
is  present  any  acute  inflammation  of  the 
stomach. 

Menthol  has  been  used  in  the  vomit- 
ing of  pregnancy.  Hourly  doses  of  a 
teaspoonful  of  the  following  are  recom- 
mended by  Hare: — 

I>  Menthol,  15  grains. 
Whisky,  6  drachms. 
Syrup,  1  ounce. — M. 

Gottschalk's  formula  is: — 

Menthol,  1  part. 
Alcohol,  20  parts. 
Distilled  water,  150  parts. 


Weil's  formula: — 

^  Menthol,  1  part. 

Olive-oil,  4  parts. 
Dose,  10  drops,  with  powdered  sugar. 

Squibb's  formula: — 

^  Menthol,  40  parts. 

Oil  of  bitter  almonds,  180  parts. 
Dose,  6  to  10  drops  on  loaf-sugar. 

Case  of  a  woman  who  had  vomited  after 
each  meal  for  three  weeks  relieved  at 
once  by  the  use  of  menthol.  In  order 
that  the  drug  may  remain  in  solution 
it  may  be  given  in  the  following  form: 
Menthol,  1;  dissolved  in  spirit  vini,  20; 
syr.  sacch.,  30.  Of  this  mixture  a  tea- 
spoonful  is  given  every  hour.  L.  Weiss 
(Wiener  med.  Woch.,  p.  496,  '90). 

Literature  of  '96-'97-'98. 

The  following  may  be  used  in  case  of 
the  vomiting  of  tuberculosis:  — 

I£  Menthol,  4  grains. 
Syrup,  5  ounces. — M. 

Shake  well  before  using  and  give  two 
or  three  teaspoonfuls  at  short  intervals 
after  each  meal. 

This  treatment  is  an  excellent  one  to 
follow  the  use  of  chloroform- water  or  ice. 
Editorial  (Jour,  des  Prat.,  Jan.  9,  '97). 

Following  mixture  recommended  to 
control  the  vomiting  of  seasickness:  — 

I£  Menthol,  1.5  grains. 

Cocaine  hydrochlorate,  3  grains. 
Alcohol,  2  ounces. 
Simple  syrup,  1  ounce. 
One  teasponful  is  to  be  given  every 
half-hour  until  several  doses  are  taken. 
A.  Morel-La  vallee  (Le  Bull.  Med.,  vol.  x, 
p.  1199,  '98). 

Painful  Disorders. — For  the  relief 
of  pain  and  pruritus,  menthol  is  an  effi- 
cient remedy  applied  in  the  form  of  a 
cone  or  pencil,  in  alcoholic  solution,  or 
in  ointment.  One  drachm  of  menthol 
may  be  dissolved  in  4  ounces  of  soap 
liniment  for  external  uses.  The  pain 
and  itching  of  herpes  zoster  and  urticaria 


600 


MENTHOL.  THERAPEUTICS. 


may  be  relieved  by  a  5-per-cent.  oint- 
ment of  menthol. 

Menthol  given  internally  with  success 
in  migraine  and  other  painful  disorders, 
the  dose  being  5  to  20  grains,  three  times 
a  day.  It  may  be  administered  in  cap- 
sules, or,  better,  in  a  20-per-cent.  alcoholic 
solution  in  a  wineglass  of  hot  water. 
Dana  (Med.  Record,  Sept.  29,  '88). 

Following  prescription  to  be  used  for 
the  internal  administration  of  menthol 
in  hemicrania,  infra-orbital  neuralgia, 
cephalalgia,  rheumatism,  and  in  sciatica. 
The  dose  varies  from  4  to  15  grains:  — 

Menthol,  2  drachms. 

Alcohol,  1  ounce. 

Glycerin,  1  ounce. 

Syrup,  1  ounce. 
M.    Sig.:    One  teaspoonful  in  warm 
water   when   required.     McLaury  (St. 
Louis  Polyclinic,  June,  '89). 

A  3-  or  even  a  6-per-cent.  solution  in 
spirit  found  more  effective  in  pruritus 
than  boric  or  salicylic  acid.  An  ointment 
of  it  made  with  lanolin  is  very  useful  in 
pruritus  senilis.  Saalfeld  (Viertel.  f. 
Derm.  u.  Syph.,  H.  1,  '88). 

Oleic  acid  recommended  as  a  useful 
solvent  of  menthol.  Two  hundred  grains 
of  the  latter  may  be  dissolved  in  1/2  fluid- 
ounce  of  the  acid,  and  the  combination 
forms  a  valuable  remedy  in  pruritic  affec- 
tions. Remington  (Amer.  Pract.  and 
News,  Mar.  13,  '88). 

Menthol  used  with  success  in  all  pru- 
riginous  affections  of  the  skin,  especially 
when  aggravated  by  scratching,  as  in 
xirticaria,  some  varieties  of  eczema,  and 
scabies.  It  may  be  prescribed  in  a  5-per- 
cent, alcoholic  solution,  a  10-per-cent.  oily 
solution,  ointments  of  1  to  6  per  cent., 
and  powders  of  2  to  G  per  cent.  Care 
must  be  taken  not  to  apply  too-concen- 
trated solutions  to  the  irritated  surfaces 
or  the  mucous  membranes,  as  a  very 
intense  sensation  of  burning  may  be 
caused;  'and  also  not  to  make  too  ex- 
tensive applications  at  once,  on  account 
of  the  disagreeable  sensation  of  cold.  As 
the  itching  is  but  a  symptom  of  the  dis- 
ease, it  is  necessary  to  prescribe  for  the 
latter,  as  the  menthol  relieves  only  the 
itching.  Colombini  (Wiener  med.  Presse, 
May  7,  '93). 


Naso-Laryngeal  Disorders. — Men- 
thol may  be  used  as  a  depletant  on  the 
mucous  membranes  of  the  nose  or  throat. 
It  causes  a  contraction  of  the  local  blood- 
vessels, which,  unlike  the  action  of  co- 
caine, is  not  followed  by  an  increased 
dilatation.  Dissolved  in  oil  (6  grains 
to  1  ounce)  or  in  albolene  or  blandin 
(5  grains  to  the  ounce)  it  may  be  used 
in  spray  for  the  relief  of  acute  coryza  and 
the  nasal  form  of  hay  fever,  A  mixture 
of  menthol  and  carbonate  of  ammonium 
may  be  used  for  the  same  purposes,  either 
being  inhaled  from  a  wide-mouthed  bot- 
tle or  an  inhaling-tube. 

Thirty-seven  cases  of  diphtheria  (in  3 
adults  and  34  children)  treated  success- 
fully by  painting  with  a  10-per-cent.  alco- 
holic solution  of  menthol.  The  paintings 
(using  cotton-wool)  were  usually  carried 
out  three  times  daily.  In  some  cases, 
however,  a  single  free  application  was  fol- 
lowed by  complete  disappearance  of  false 
membranes  within  two  days.  A  marked 
improvement  in  the  patients'  general  con- 
dition was  invariably  noticed  from  the 
beginning  of  the  treatment.  F.  Kastorsky 
(Wratsch,  No.  24,  '94). 

Pulmonary  Disorders. — Inhalations 
of  menthol  have  been  used  with  advan- 
tage in  asthma.  Being  readily  volatilized 
by  the  addition  of  hot  water,  the  re- 
sultant vapor  may  be  inhaled. 

A  few  drops  of  a  20-per-cent.  solution 
of  menthol  in  olive-oil  by  inhalations  ad- 
ministered to  a  woman  with  asthma  and 
congestion  of  the  head.  Before  adminis- 
tration crepitation  and  rhonchi  were 
heard  on  pulmonary  auscultation.  The 
remedy  always  checked  the  asthmatic 
attack:  breathing  became  normal,  the 
heart's  action  remained  unaltered,  and 
the  pulse  full  and  strong.  The  patient 
sometimes  complained  of  dizziness.  -lores 
(Ther.  Monats.,  Apr.,  '89). 

Intralaryngeal  injections  of  10-  to  15- 
per-cent.  solutions  of  menthol  in  olive- 
oil  or  vaselin  have  been  used  in  pulmo- 
nary tuberculosis  and  ulcerations  of  the 


MENTHOL.  THERAPEUTICS. 


601 


larynx.  These  injections  often  relieve 
the  dyspnoea  and  cough  associated  with 
phthisis. 

Menthol  successfully  employed  in  the 
treatment  of  pulmonary  and  laryngeal 
tuberculosis,  according  to  the  suggestions 
of  Koshlakoff  and  Simanovsky.  In  8  out 
of  12  cases  it  was  found  that:  (1)  the 
menthol  treatment  was  followed  by  a 
great  amelioration  of  the  general  condi- 
tion of  the  patient;  (2)  the  remedy  im- 
proved the  appetite,  promoted  easy  ex- 
pectoration, and  gradually  decreased  the 
daily  quantity  of  the  sputa;  (3)  the 
drug  never  gave  rise  to  any  renal  irrita- 
tion; and  (4)  it  never  induced  haemop- 
tysis. In  the  15  cases  of  laryngeal  tuber- 
culosis treated  with  menthol,  the  drug 
was  found  to  possess  considerable  anal- 
gesic action.  The  paintings  decreased 
local  inflammatory  phenomena  and  did 
away  with  infiltrations.  They  also  pro- 
moted healing  of  superficial  ulcers,  but 
could  not,  however,  bring  about  cicatriza- 
tion of  deep  ulcerations.  It  is  advisable 
always  to  begin  with  a  10-per-cent.  solu- 
tion, and  to  gradually  increase  this 
strength.  In  all  cases  the  local  must  be 
accompanied  by  general  treatment. 

In  pulmonary  tuberculosis  the  drug- 
was  administered  internally,  as  in  the  fol- 
lowing prescription:  — 

R<  Mentholi,  1  drachm. 

Pulv.  acaeise  sacchari  albi,  of  each, 
V2  drachm. 
M.  et  ft.  pil.  No.  40. 

Of  these  pills,  5  are  to  be  taken,  gradu- 
ally increasing  the  number  to  20,  30,  and 
even  40.  The  inhalations  were  used  from 
ten  to  twelve  times  a  day.  The  paintings 
were  applied  with  from  10-  to  50-per-cent. 
solution,  once  daily,  once  every  two  days 
or  twice  a  week,  according  to  indications. 
Valerius  Idelson  (Wratsch,  No.  3,  '90). 

Injection  into  the  larynx  of  a  20-per- 
cent, solution  of  menthol  in  olive-oil 
advised  in  laryngeal  and  pulmonary 
phthisis.  At  each  sitting  two  to  three 
injections  of  15  minims  each  should  be 
given,  the  fluid  being  deposited  on  the 
part  affected  when  the  larynx  is  diseased, 
but  in  the  trachea  when  the  lungs  only 
are  involved.    The  procedure  should  be 


carried  out  once  or  twice  daily  for  about 
two  months.  Ulcers  of  the  larynx  heal 
nicely  under  it.  A.  J.  Beehag  (Edinburgh 
Med.  Jour.,  Jan.,  '88). 

Attention  called  to  the  parasiticidal 
powers  of  menthol,  a  remedy  that  may 
be  daily  applied  through  the  trachea  in 
the  treatment  of  pulmonary  consump- 
tion, using  doses  of  1  drachm  of  a  12-per- 
cent, solution  made  with  sterilized  oil. 
Administered  in  this  manner,  the  drug 
was  well  borne  by  patients,  and  under 
its  use  the  cough,  expectoration,  night- 
sweats,  the  hectic  fever,  and  even  the 
emaciation  were  diminished.  Brook- 
house  (Revue  Gen.  de  Clin,  et  de  Ther., 
Aug.  3,  '92). 

Eak  Diseases. — Mentholized  oil  (10 
to  15  per  cent.)  has  been  recommended 
in  the  treatment  of  furuncle  of  the  ex- 
ternal auditory  canal,  and  of  diffuse 
swelling  of  the  wall  of  the  canal.  A 
pledget  of  cotton  soaked  in  the  mentho- 
lized oil  is  inserted  into  the  meatus  and 
left  for  twenty-four  hours.  A  burning 
sensation  is  produced,  but  it  soon  passes 
off.  In  the  painful  stage  of  otitis  media 
without  perforation,  mentholized  oil  (1 
to  2  per  cent.),  instilled  into  the  meatus, 
is  a  useful  anodyne  application.  In 
chronic  otitis  media  mentholized  oil  (5 
to  10  per  cent.)  is  valuable  as  a  mild 
antiseptic  for  the  interior  of  the  tym- 
panum. 

Local  Anesthesia. — Squibb  advises 
the  following  solution  for  local  anaesthe- 
sia that  will  last  about  five  minutes,  an 
ordinary  hand-spray  apparatus  being 
used: — 

^  Menthol,  2  parts. 
Chloroform,  20  parts. 
Ether,  31  parts,— M. 

Equal  parts  of  chloral  and  menthol 
form,  upon  trituration,  an  oily  substance 
which  is  mildly  counter-irritant  and  a 
local  anaesthetic. 

Mixture  of  equal  parts  of  menthol  and 
iodoform  in  the  form  of  a  dry  powder 


602 


MERCURY.    PHYSIOLOGICAL  ACTION. 


tried  in  fourteen  cases  of  scraping  out 
and  resection  of  tuberculous  bones  and 
soft  parts.  In  every  instance  the  wound 
healed  more  rapidly,  and  the  general 
course  of  the  case  was  more  favorable 
than  in  another  series  of  similar  cases 
where  iodoform  alone  was  employed. 
Girard  (Brit,  Med.  Jour.,  Apr.  28,  '88). 

C.  Sumner  Witherstine, 

Philadelphia. 

MERCURY. — Mercury,  hydrargyrum, 
or  quick-silver,  is  a  lustrous,  bluish- 
silver-white  metal  liquid  which,  though 
occasionally  found  in  its  pure  state,  is 
usually  obtained  from  native  chloride  or 
sulphide.  It  is  also  found  in  amalgama- 
tion with  silver.  The  sulphide,  called 
native  cinnabar,  is  mainly  obtained  in 
the  mines  of  Almaden,  Spain,  and  of 
New  Almaden,  near  San  Jose,  California. 
The  various  processes  through  which  it 
is  isolated  are  all  based  upon  distillation. 

Mercury  is  devoid  of  odor  or  taste. 
At  the  usual  temperature  of  temperate 
countries  it  occurs  as  a  heavy  fluid,  but 
at  38.88°  below  zero  F.  it  becomes  solid, 
though  quite  malleable.  When  it  is  ex- 
posed to  high  heat  (675.05°  F.)  it  vola- 
tilizes into  a  colorless  vapor.  It  is  solu- 
ble in  nitric  acid  and  boiling  sulphuric 
acid. 

Physiological  Action. — Blood. — Wil- 
bouchewitch  showed  that  large  doses  of 
mercury  caused  reduction  of  the  red 
blood-corpuscles  and  that  small  doses 
prevented  their  destruction.  When,  how- 
ever, small  doses  were  administered  dur- 
ing too  prolonged  a  period,  anaemia  was 
again  observed.  E.  L.  Keyes,  in  a  series 
of  experiments,  further  demonstrated 
that  small  doses  of  mercury  not  only 
arrested  the  destruction  of  corpuscles 
due  to  syphilis,  but  that  they  actually 
caused  an  increase  which  steadily  pro- 
gressed until  a  normal  proportion  was  at- 
tained, as  long  as  the  small  doses  were 
given.   Large  doses  he  found  to  exert  an 


opposite  influence,  being  distinctly  de- 
bilitating. Eobin,  acting  on  these  con- 
clusions, found  that  in  syphilitic  or  non- 
syphilitic  subjects,  and  whatever  way  it 
was  administered,  mercury  always  caused 
an  increase  of  blood-corpuscles  provided 
an  intercurrent  gastric  disorder  were  not 
present  or  the  untoward  effects  of  mur- 
cury  —  salivation,  etc.  —  were  not  pro- 
duced. The  onset  of  these  disorders 
marked  the  beginning  of  hypoglobulia 
— decrease  in  the  number  of  corpuscles. 

Observations  in  regard  to  the  amount 
of  haemoglobin  present  in  syphilis  in  re- 
lation to  the  benefit  derived  from  mer- 
curial treatment.  Three  incontestable 
facts  are  (1)  that  if  a  syphilitic  patient 
has  no  treatment,  the  quantity  of  haemo- 
globin in  the  blood  will  diminish  from 
time  to  time;  (2)  that  if  mercury  be 
given  to  animals  or  persons  not  suffer- 
ing from  syphilis,  the  amount  of  haemo- 
globin will  be  diminished  in  a  few  days; 
(3)  that  if  a  syphilitic  person  who  shows 
that  the  amount  of  haemoglobin  is  di- 
minishing be  put  on  a  mercurial  treat- 
ment, an  increase  in  the  amount  of  haemo- 
globin can  be  determined  at  once,  and 
very  markedly  in  the  course  of  seven  or 
eight  days.  From  these  facts  we  have  a 
valuable  indication  as  to  just  when  our 
mercury  ceases  to  do  good,  and  therefore 
should  be  stopped.  Semmola  (La  Presse 
Med.,  Sept.  15,  '89). 

The  comparative  influence  of  mercury 
upon  the  blood  was  recently  studied  by 
Kuperwasser  (Arch,  des  Sci.  Biol,  de  St. 
Petersburg,  vol.  vi,  '98).  He  found  that 
white  corpuscles  (which  all  arise  from 
one  and  the  same  element, — namely:  the 
small  mononucleated  lymphocyte)  being 
classified  into  (1)  young,  (2)  mature,  and 
(3)  old,  leucocytes,  the  blood  of  healthy 
subjects  was  modified  by  mercury  in  that 
the  proportion  of  young  leucocytes  pres- 
ent is  considerably  increased  and  that  of 
the  old  considerably  diminished.  The 
blood  of  syphilitics  reacts  to  mercury  by 
I  a  considerable  diminution  in  the  propor- 


MERCURY.    PHYSIOLOGICAL  ACTION. 


603 


tion  of  young  and  a  corresponding  in- 
crease in  that  of  old  leucocytes.  This 
reaction  is  independent  of  the  stage  of 
the  disease,  and  takes  place  whether 
there  are  at  the  time  syphilitic  mani- 
festations or  not,  and  also  whether  the 
patient  has  or  has  not  previously  been 
subjected  to  specific  treatment  of  mer- 
cury and  iodides.  Those  who  have  un- 
dergone treatment  by  mercury  within 
four  months  of  applying  the  blood-test 
form  the  only  exception  to  this  rule.  In 
such  cases  the  reaction  of  syphilitic  is  re- 
placed by  that  of  healthy  blood,  possibly 
because  the  patient  still  retains  a  con- 
siderable quantity  of  mercury,  or  because 
under  its  influence  the  disease  has  be- 
come so  attenuated  that  the  blood  gives 
a  normal  reaction. 

Older  observers  had  noted  a  diminu-  j 
tion  of  fibrin,  and  as  a  result  an  abnor- 
mal fluidity  of  the  blood  that  predis- 
posed to  haemorrhage.  Lowering  of  the 
rate  and  tension  of  the  pulse  and  of  the 
temperature,  sometimes  of  nearly  two 
degrees,  was  also  noted:  all  evidences 
that  the  remedy  had  been  administered 
in  injudicious  doses. 

Bichloride,  in  high  toxic  doses,  exer- 
cises a  noxious  influence  on  both  the 
white  and  red  cells  of  the  blood.  In  small 
amounts  it  affects  the  white  corpuscles 
more  markedly  than  the  red  bodies.  The 
minimum  fatal  quantities  for  the  organ- 
ism correspond  to  the  smallest  amounts 
necessary  to  destroy  the  leucocytes;  the 
same  relation  exists  in  regard  to  the 
largest  quantities  tolerated  by  the  econ- 
omy and  those  which  are  borne  by  the 
leucocytes;  and  it  can  be  said  that  at 
present  there  is  no  histological  element 
so  susceptible  to  the  influence  of  the 
drug  in  question  as  human  leucocytes. 
E.  Maurel  (Bull.  Gen.  de  Ther.,  Mar.  15, 
'93). 

Kidneys. — The  observations  of  Wel- 
ander  tend  to  show  that  the  elimination 
of  mercury  through  the  kidneys  is  at-  I 


tended  by  more  or  less  temporary  irrita- 
tion when  the  drug  is  administered  for 
some  time.  Casts  were  found  in  the 
urine  in  all  of  his  97  cases,  in  propor- 
tion to  the  length  of  the  treatment, 
gradually  decreasing  after  cessation  and 
disappearing  within  a  month  or  six 
weeks.  It  is  well  to  bear  in  mind,  how- 
ever, that  his  data  are  based  upon  ob- 
servations in  syphilitic  cases,  and  that 
the  disease  may  bear  considerable  influ- 
ence upon  the  renal  phenomena. 

Syphilitic  patients  under  mercurial 
treatment  frequently  develop  nephritis. 
Out  of  100  patients,  8  had  developed 
albuminuria  in  consequence  of  the  ab- 
sorption of  mercury.  These  cases  always 
tended  to  recovery  on  the  cessation  of  the 
drug.  Fiirbringer  (Med.  Week,  July  13, 
'94). 

As  regards  the  quantity  of  urine,  vari- 
ous preparations  were  found,  by  Win- 
ternitz,  to  differ  in  no  way.  His  experi- 
ments included  the  insoluble  salts,  calo- 
mel, salicylate  of  mercury,  and  the  solu- 
ble preparations.  A  parallelism  between 
the  quantity  introduced  and  the  curative 
effect  was  shown  by  the  quantity  ex- 
creted, whether  the  mode  of  administra- 
tion was  by  the  mouth,  subcutaneous  in- 
jection, local  inunction,  or  plaster. 

Intestinal  Teact. — Schuster,  as  al- 
ready stated,  found  mercury  in  the  faeces 
three  months  after  cessation  of  the  treat- 
ment. This  author  is  of  the  opinion  that 
the  intestinal  tract  is  far  more  active 
than  the  kidneys  in  the  process  of  elim- 
ination, and  that  mainly  through  its 
means  the  system  is,  as  a  rule,  relieved 
of  its  mercury  six  months  after  an  aver- 
age course  of  treatment.  In  poisoning 
by  mercury  the  intestinal  tract  seems  to 
bear  the  brunt  of  the  attack,  especially 
the  large  intestine.  Pilliet  and  Cathe- 
lineau  found  extreme  congestion  of  the 
vascular  net-work,  with  necrosis  of  the 
glandular  net-work,  in  this  situation. 


604 


MERCURY.    PHYSIOLOGICAL  ACTION. 


Frankel  found  that  the  inflammation;, 
even  when  mercury  is  used  externally, 
attacked  the  large  intestine  and  the 
ileum  only  exceptionally. 

Anatomical  specimens  from  a  patient 
who  had  received  hypodermic  injections 
of  metallic  mercury.  The  intestine  was 
dotted  with  numerous  ulcers  and  diph- 
theroid thickenings,  and  the  kidneys 
were  of  the  small,  white  type.  Audry 
(Lyon  Med.,  Apr.  15,  '88). 

Calomel  has  a  marked  disinfectant 
effect  upon  the  intestinal  canal,  which 
depends  upon  the  transformation  of  the 
drug  into  an  oxide  of  mercury  through 
the  influence  of  the  bile  and  the  alkalies 
of  the  intestinal  canal.  Sawadsky  (Jour, 
des  Sci.  Med.  de  Lille,  Mar.  16,  '88). 

Literature  of  '96-'97-'98. 

When  calomel  is  given,  even  in  thera- 
peutic doses,  and  the  subject  is  then 
made  to  drink  saline  or  chlorhydrated 
water,  much  more  rapid  and  intense 
symptoms  are  induced  than  when  the 
calomel  is  administered  alone. 

In  these  cases  it  is  probable  that  the 
calomel  only  acts  while  going  through 
the  albuminoid  substances  of  the  body; 
it  irritates  the  digestive  tube,  giving  rise, 
in  the  first  place,  to  diarrhoea  and  vomit- 
ing and  afterward  to  alterations  in  the 
mucous  membrane.  This  toxic  and  irri- 
tating action  of  the  calomel  is.  however, 
principally  observed  when  it  is  in  con- 
tact with  substances  which  render  it 
more  soluble  and  more  absorbable. 
Among  these  substances,  chloride  of 
sodium  and  chlorhydric  acid,  associated 
with  various  albuminoid  substances, 
come  first  in  order.  These  substances  do 
not  act  by  chemically  transforming  the 
calomel  into  a  more  toxic  agent, — i.e., 
corrosive  sublimate.- — but  simply  by 
facilitating  its  absorption  in  a  nia<>. 
Ottolenghi  (Gaz.  Osped.,  Xo.  1,  '97). 

Nutrition. — Thirty  years  ago  Liegeois 
stated  thai  personal  observations  had  led 
him  to  conclude  that  even  in  healthy 
men  very  small  doses  of  mercury  led  to 
an  increase  of  weight.  Schlesinger,  in 
a  series  of  experiments  in  sheep,  rabbits,' 


and  dogs,  also  noted  this  fact.  Having 
administered  the  corrosive  sublimate  an 
entire  year,  he  found  that  all  the  animals, 
especially  the  dogs,  so  treated  had  gained 
in  weight  and  that  there  had  been  a 
marked  increase  of  red  corpuscles,  while 
all  the  untreated  check  animals  did  not 
present  these  changes.  Schlesinger  con- 
tends, however,  that  the  increase  in 
weight  being  due  to  an  increase  of  fat, 
the  only  conclusion  warranted  is  that  a 
diminution  of  oxidation  occurs,  the  re- 
sult of  restricted  protoplasmic  metab- 
olism, the  red  cells  increasing  merely 
because  the  destruction  was  curtailed. 
The  tonic  effects  of  mercury  would  thus, 
in  his  opinion,  be  but  apparent;  were 
they  real  an  elevation  of  temperature 
and  an  increase  of  organic  exchanges 
would  be  present.  In  the  opinion  of  H. 
C.  AVood,  this  view  rests  upon  theory 
rather  than  upon  demonstrated  facts, 
there  being  much  clinical  testimony  to 
sustain  the  assertion  that  exceedingly 
minute  doses  of  mercury  benefit  nutri- 
tion. The  fact  that  von  Boeck  found 
an  increase — though  slight — of  nitrogen 
in  the  faeces  and  urine  under  mercury 
tends  to  sustain  Wood's  contention. 

Absorption  and  Elimination. — Al- 
though there  is  no  doubt  whatever  that, 
mercury  is  absorbed  and  eliminated,  the 
manner  in  which  the  process  is  carried 
on  is  not  fully  understood.  11.  C.  Wood 
concludes  from  data  at  hand  that  "the 
single  dose  of  mercury  does  not  remain 
in  the  system,  but  that  when  the  drug 
is  administered  constantly  for  a  length 
of  time  elimination  does  not  keep  pace 
witli  absorption,  so  thai  the  mercury  ac- 
cumulates in  the  tissues.'' 

When  applied  to  the  skin,  mercury  has 
been  traced  microscopically  as  far  as  the 
hair-bulb,  where  it  has  thought  until 
recently  to  become  transformed  into 
corrosive  sublimate  (Neumann).  The 


MERCURY.    PHYSIOLOGICAL  ACTION. 


605 


same  chemical  transformation  was  be- 
lieved by  many  observers,  including 
Nothnagel  and  Rossbach,  to  occur  in  the 
intestinal  tract.  In  the  presence  of 
albuminous  substances  the  new  salt  was 
credited  with  the  power  of  forming  an 
insoluble  albuminate,  which  became  solu- 
ble in  the  presence  of  chloride  of  sodium. 

Recent  labors,  however,  having  demon- 
strated the  extreme  power  of  volatiliza- 
tion of  mercury  (it  has  an  initial  molec- 
ular velocity  of  180  metres  per  second, 
according  to  Merget),  and  the  theory 
has  been  vouchsafed  that  in  its  normal 
or  metallic  state  it  penetrated  the  cu- 
taneous and  intestinal  mucous  surfaces 
(Rabuteau;  quoted  by  Jullien,  "Maladies 
Veneriennes,"  p.  1161).  The  protiodide, 
for  instance,  would  become  transformed 
into  metallic  mercury  and  biniodide,  the 
latter,  in  turn,  being  decomposed  and 
giving  rise  to  the  iodide  of  sodium  found 
in  the  urine;  calomel  would  yield  pure 
mercury  and  bichloride,  which,  in  turn, 
would  slowly  be  transformed  into  chlo- 
ride of  sodium  and  metallic  mercury  in 
the  blood.  Thus,  any  preparation  of 
mercury  would  finally  yield  its  original 
element.  This  theory,  according  to 
Jullien,  of  Paris,  a  syphilographer  of  ex- 
tensive experience,  is  sustained  by  much 
clinical  evidence.  He  alludes  to  the 
many  instances  in  which  metallic  mer- 
cury has  been  found  in  various  tissues 
(Van  Swieteu),  the  pus  of  abscesses 
(Maid ore),  bones  (Hyrtl),  etc. 

As  regards  the  accumulation  of  mer- 
cury in  the  organism,  Vajda  and  Pasch- 
kis  and  Sigismund  found  it  in  the  urine 
thirteen  years  after  cessation  of  mer- 
curial treatment,  but  Schuster  attributed 
this  resnlt  to  faulty  technique  in  the 
ease  of  the  first  observers  and  to  con- 
stant exposure  of  the  subject  to  diffused 
mercury,  in  the  case  of  Sigismund.  Still, 
Schuster  himself  found  it  in  the  faeces 


months  after  the  treatment  has  been 
stopped. 

In  administration  of  the  insoluble  salts 
of  mercury  the  metal  may  be  found  de- 
posited in  the  following  organs,  those 
containing  the  larger  amounts  being  first : 
Kidneys,  liver,  spleen,  then  the  intestinal 
canal  (which  contains  an  increasing  por- 
tion from  the  upper  part  downward), 
and  in  small  amounts  in  the  heart  skele- 
tal muscles,  and,  in  some  cases,  in  the 
lungs  arid  in  the  blood  collected  in  the 
larger  vessels  and  the  aorta.  Karl  Ull- 
mann  (Inter,  klin.  Rund.,  Sept.  25,  '92). 

As  to  its  elimination,  this  depends 
upon  the  manner  in  which  it  is  admin- 
istered. Byasson  and  Betelli  found  mer- 
cury in  the  urine  and  saliva  two  hours 
after  ingestion.  Riederer  obtained,  from 
the  fasces  of  a  dog,  77  per  cent,  of  the 
quantity  administered  during  thirty 
days,  and  from  its  urine  1  per  cent. 
The  brain,  heart,  lungs,  spleen,  pancreas, 
testicles,  penis,  muscles,  and  liver  were 
all  found  to  contain  mercury:  the  liver 
the  most  and  the  muscles  the  least.  It 
has  also  been  found  in  the  milk  of  nurs- 
ing-women, and  their  sucklings,  and  in 
semen.  The  experiments  of  Magengon 
and  Bergeret  would  tend  to  show,  how- 
ever, that  a  single  dose  of  mercury  is 
completely  eliminated. 

After  a  single  dose  of  mercury  its  elimi- 
nation is  rapid  and  sometimes  complete 
in  twenty-four  hours,  but  if  a  continuous 
treatment  is  interrupted  its  excretion 
continues  for  some  time,  and  Kiissmaul 
and  Gorup-Besanez  have  found  it  in  the 
liver  as  much  as  a  year  after  its  adminis- 
tration had  been  stopped.  The  amount 
of  mercury  that  can  be  steadily  elimi- 
nated for  many  weeks  from  the  kidneys 
when  the  body  is  saturated  is  about  Vie 
grain. 

The  practical  conclusions  to  bo  drawn 
from  those  researches  is  that  it  is  well 
to  stop  the  administration  of  mercury 
when  tlio  amount  eliminated  by  the  urine 
has  reached  its  normal  maximum.  M.  F. 
Balzar  and  Mile.  Klumpke  (Revue  do 
Mod..  Apr..  '88). 


606 


MERCURY.    UNTOWARD  EFFECTS. 


Untoward  Effects  of  Mercury. — When 
there  exists  in  the  individual  treated  an 
unusual  sensitiveness  to  mercury  or  the 
drug  be  given  too  long  or  in  excessive 
quantities,  symptoms  appear  that  are 
quite  pathognomonic.  There  is,  at  first, 
disagreeable  metallic  taste,  the  breath  is 
foetid, — the  fceter  of  dead  tissue, — the 
gums  are  sensitive,  and  when  the  jaws 
are  forcibly  closed  slight  pain  is  experi- 
enced. At  the  same  time  the  saliva  be- 
comes more  free  than  usual.  If  as  soon 
as  these  symptoms  appear  the  adminis- 
tration of  the  drug  is  not  stopped,  as 
should  always  oe  the  case,  the  gums  be- 
come spongy  and  bleed  easily;  the  tongue 
swells,  and  the  flow  of  saliva  becomes  ex- 
cessive,— ptyalism.  If  the  gums  be  exam- 
ined, a  dark  line  will  be  found  at  their 
junction  with  the  teeth.  The  parotid 
and  maxillary  glands  are  usually  en- 
larged and  tender,  and  there  may  be 
slight  fever. 

Catharsis  and  mild  ptyalism  followed 
2-  to  3-grain  doses  of  the  yellow  subsul- 
phate  of  mercury  (turpeth  mineral), 
given  to  produce  vomiting  in  a  child  of 
three  years.  Bradford  Woodbridge  (Occi- 
dental Med.  Times,  Mar.,  '91). 

Case  of  salivation  in  a  child  from  less 
than  2  grains  of  calomel.  Krotoszyner 
(Occidental  Med.  Times,  Mar.,  '96). 

Case  in  which  ptyalism  was  produced 
by  the  local  application  of  black  wash. 
T.  J.  Walker  (Brit.  Med.  Jour.,  Nov.  28, 
'91). 

Persistence  in  the  use  of  mercury  after 
these  manifestations  is  followed  by  local 
destructive  changes.  Ulceration  of  the 
mucous  membrane,  soon  invading  the 
deeper  tissues,  looseness  and  loss  of  the 
teeth,  necrosis  of  the  jaw-bones,  copious 
haemorrhages  occurring  through  ulcera- 
tion of  the  vascular  coats,  follow  in  more 
or  less  rapid  succession,  and  the  patient 
dies  of  exhaustion.  It  is  rare  that  such 
a  result  occurs  nowadays.  The  cases  of 
mercurial  poisoning  usually  met  with 


are  usually  due  to  insufficient  instruc- 
tions to  the  patient,  who  continues  to 
use  the  remedy  without  consulting  his 
physician. 

In  some  cases  the  skin  is  first  to  show 
the  mercurial  manifestations,  an  erup- 
tion resembling  that  of  scarlatina  being 
that  most  frequently  observed.  Great 
suffering  is  sometimes  entailed,  as  shown 
in  Camescasse's  case  given  below. 

Case  of  a  man,  45  years  of  age,  in  whom 
mercurial  inunctions  were  followed  by 
severe  ptyalism,  painful  tongue,  loosened 
teeth,  foetid  breath,  a  papular  and  pus- 
tular eruption  accompanied  by  intense 
itching,  and  a  purpuraceous  desquama- 
tion. The  temperature  was  raised  to  102° 
F.,  and  there  were  produced  also  loss  of 
appetite,  tremor,  albuminuria,  and  other 
symptoms.  The  patient  finally  recovered 
under  proper  treatment.  He  exhibited, 
some  time  later,  the  same  train  of  symp- 
toms after  the  administration  internally 
of  10  grains  of  calomel  divided  in  four 
doses.  The  eruption  now  was  of  a  mili- 
ary and  scarlatiniform  character.  The 
primary  symptoms  were  chills  and  fever 
at  night.  Robinson  (Med.  Analectic  and 
Epit.,  Aug.,  '90). 

Instance  of  erythema  searlatinoides 
following  the  application  of  mercurial 
ointment  to  the  pubic  region  in  which 
diagnosis  of  scarlatina  was  made  by  a 
physician.  Within  a  week  there  followed 
abundant  desquamation  from  the  entire 
body,  especially  profuse  on  the  hands 
and  feet.  At  no  time  was  there  an  eleva- 
tion of  temperature  nor  was  the  throat 
implicated.  Fordyce  (Jour.  Cnt.  and 
Gen.-Urin.  Dis.,  Dec,  '05). 

Literature  of  '96-97-93. 

Case  of  an  old  woman,  suffering  from 
irregular  heart-action  resulting  from  a 
long-standing  mitral  insufficiency  who 
received  five  doses  of  2/3  grain  of  calomel 
at  three-hour  intervals  on  alternate  days 
for  a  week.  Patient  was  upon  a  milk 
diet,  and  received  a  simple  clyster  each 
morning.  Moderate  purgation  and  con- 
siderable diuresis  ensued,  with  consequent 
diminution  of  anasarca  and  dyspnoea. 
Upon  the  day  following  the  first  day's 


MERCURY. 

use  of  the  drug  there  was  noticed  a  slight 
burning  over  the  entire  body,  but  espe- 
cially over  the  face,  neck,  and  hands. 
The  second  day  redness  appeared.  At 
the  end  of  the  week  the  burning  was 
atrocious,  the  entire  surface  of  the  skin 
was  scarlet  red,  violet  in  places,  swelled, 
and  thickened.  The  hairy  scalp  remained 
imcolored.  The  palms  and  soles  were 
less  colored  than  the  other  surfaces,  but 
yet  were  red.  In  a  few  days  spontaneous 
cure  appeared,  but  accompanied  by  an 
abundant  and  extraordinary  desquama- 
tion, which  extended  to  the  hairy  scalp 
and  to  the  mucous  surfaces.  First,  large 
surfaces  were  detached,  then  small  scales, 
and  finally  a  whitish  powder.  This  proc- 
ess lasted  fifteen  days,  although  the  mu- 
cous surfaces  were  healed  at  an  earlier 
period.  There  was  not  any  elevation  of 
temperature,  nor  did  the  redness  of  the 
mouth  resemble  a  mercurial  stomatitis. 
Camescasse  (Bull.  Gen.  de  Ther.,  le.  liv., 
p.  20,  '98). 

Untoward  symptoms  of  mercurial  poi- 
soning do  not  only  manifest  themselves 
as  a  result  of  the  therapeutic  use  of  mer- 
cury; they  are  often  brought  about  by 
the  handling  of  mercury  as  an  occupa- 
tion or  the  inhalation  of  its  fumes.  This 
is  termed  "chronic  mercurial  poisoning/' 

Chronic  Mercurial  Poisoning. — 
When  the  metal  is  inhaled  in  the  form 
of  a  vapor,  the  nervous  system  is  most 
apt  to  suffer,  and  paralysis  is  a  frequent 
sequel.  The  palsy  may,  after  long  ex- 
posure, come  on  suddenly  or  slowly; 
there  is  a  sort  of  general  tremor  and 
great  unsteadiness  in  all  movements,  in- 
cluding those  involved  in  locomotion, 
and  the  skin  becomes  dark  yellow  or 
brown.  Mental  debility  may  appear,  the 
precursor  of  an  early  demise.  The  mani- 
festations often  simulate  chorea  and  pa- 
ralysis agitans.  The  disease  may  assume 
various  special  forms,  certain  parts  being 
more  involved  than  others.  In  some 
wrist-drop  is  a  marked  feature,  in  others 
there  may  be  a  brachial  or  crural  mono- 
plegia, etc.   The  special  senses  are  often 


POISONING.  607 

impaired  and  disorders  of  sensation  are 
frequently  observed.  Neuralgia  is  a 
prominent  feature  of  these  cases. 

Case  of  typical  polyneuritis  following 
a  prolonged  course  of  inunction  of  mer- 
cury in  the  treatment  of  an  attack  of 
syphilis.  Ley  den  (Deut.  med.  Woch., 
Aug.  3,  '93). 

Three  cases  of  pronounced  multiple 
neuritis  from  the  therapeutic  use  of  mer- 
cury. Recovery  occurred  in  all.  Spill- 
mann  and  Etienne  (Rev.  de  Med.,  Dec. 
10,  '95). 

Mercurial  Cachexia. — This  condi- 
tion resembles  scurvy  and  may  result 
from  professional  exposure  to  the  effects 
of  mercury  or  as  a  sequence  of  treatment. 
There  is  marked  anaemia  and  loss  of 
flesh,  alopecia,  general  loss  of  power  and 
all  the  local  manifestations  of  mercurial 
toxaemia:  foul  breath,  diarrhoea,  and  a 
dark  color  of  the  skin.  There  is,  besides, 
intense  pain  in  the  bones  and  joints,  sug- 
gesting rheumatism. 

Poisoning  of  Mercury. — Whatever  be 
the  preparation  of  mercury  ingested  in 
poisonous  quantities,  the  symptoms  are 
very  similar,  the  only  difference  worth 
noting  being  the  rapidity  of  onset.  The 
majority  of  accidental  cases  met  with  are 
usually  instances  of  bichloride  poisoning. 
If  the  dose  taken  is  large  and  concen- 
trated, there  is  nausea,  vomiting,  faint- 
ness,  impaired  locomotion,  and  severe 
pain  in  the  throat  and  chest.  There  is 
violent  diarrhoea,  cramps;  at  first  the 
urine  is  freely  voided;  later  on  anuria 
occurs.  The  lips,  tongue,  and  pharynx 
may  be  tumefied,  and  dysphagia  be  so 
marked  as  to  prevent  swallowing  of  rem- 
edies. After  several  hours  the  breath 
becomes  excessively  foetid,  great  saliva- 
tion occurs,  and  ulcers  appear  on  the 
inner  aspect  of  the  lips  and  cheeks,  and 
sometimes  the  tongue.  The  gums  be- 
come spongy.  Gradually  the  local  symp- 
toms become  more  marked  and  the  pa- 


(308  MERCURY.  POISONING. 


tient  dies.    A  fatal  ending  rarely  occurs 

the  same  day. 

Case  in  which  a  woman  was  poisoned 
through  drinking,  at  one  draught,  a 
tumblerful  of  tepid  water,  in  which 
a  5  -  per  -  cent,  sublimate  pastille  had 
been  dissolved.  Immediately  after  drink- 
ing this  she  felt  nausea,  faintness,  and 
weakness  in  the  knees,  so  that  she  could 
not  even  crawl  into  bed.  Directly  she 
was  placed  in  bed  violent  choking  sensa- 
tions set  in  and  she  vomited  bile-stained 
mucus.  One  hour  and  a  half  after  the 
poison  was  swallowed  the  symptoms 
mentioned  had  become  aggravated.  Gen- 
eral trembling  movements,  especially 
marked  in  the  upper  part  of  the  body, 
were  present.  The  patient  could  not 
speak,  but  by  signs  expressed  that  she 
felt  severe  pains  in  the  region  of  the 
stomach  and  pharynx  and  heaviness  in 
the  head.  The  pulse  was  rapid  and  soft, 
the  temperature  subnormal,  the  pupils 
contracted.  She  had  taken  a  quart  of 
milk,  but  found  great  difficulty  in  swal- 
lowing it.  The  whites  of  3  eggs  were 
given  at  once,  morphine,  and,  later  on, 
oil  of  camphor,  being  injected  subcutane- 
ously.  The  doses  of  albumin  were  con- 
tinued every  half-hour  during  the  day. 
Temporary  suppression  of  urine  was 
noted,  but  the  kidneys  acted  within 
twenty-four  hours;  tea  and  black  coffee 
favored  diuresis,  but  these  fluids  were 
usually  vomited  shortly  after  they  were 
swallowed.  The  symptoms  were  very 
grave  for  several  days.  The  vomiting 
ceased  gradually;  profuse  salivation  and 
ulcerative  stomatitis  set  in  on  the  third 
day,  witli  bloody  and  slimy  motions  and 
scanty  secretion  of  urine.  Albumin  and, 
occasionally,  blood  were  detected  in  the 
urine.  11  w  as  a  fortnight  before  the  pa- 
tient was  able  to  stand.  She  had  become 
extremely  emaciated,  lost  a  great  quan- 
tity of  hair,  and  noted  that  her  sight 
failed  her.  In  about  a  month  the  patient 
was  convalescent.  Eisenhari  (Centralb. 
f.  Gymik.,  Dec.  13,  '90). 

In  a  fatal  case,  that  of  a  woman  who 
had  taken  upon  an  empty  stomach  a 
large  teaspoonfu]  of  corrosive  suhlimate 
in  powder.  Durante  found  the  following 
anatomical  changes:   Sul  pericardial  ec-  I 


chymoses;  enlarged  liver,  with  subcap- 
sular ecchymoses;  pale,  swelled  kidneys, 
with  small  ecchymoses  in  the  pelves; 
oesophagus  reddened  at  its  upper  part, 
normal  below;  stomach  showed  a  soft- 
ened mucosa,  with  numerous  ecchymosed 
patches  and  large,  grayish  ulcerations, 
most  marked  near  the  fundus;  intestinal 
mucosa  showed  limited  areas  of  deep  red- 
dening, with  ulcerations,  the  changes  in 
the  large  intestine  being  less  than  those 
in  the  ileum;  the  brain  showed  injection 
of  the  vascular  meninges. 

Lesion  found  in  a  case  of  poisoning  by 
the  cyanide  of  mercury  to  very  closely 
resemble  those  seen  in  mercuric-chloride 
poisoning.  As  patient  lived  eight  days 
after  the  taking  of  the  poison,  patho- 
logical changes  were  well  marked.  The 
lowest  portion  of  the  ileum  was  the  most 
affected  part  of  the  digestive  tract,  and 
the  kidneys  were  found  to  be  impreg- 
nated with  lime-salts  to  a  marked  degree. 
Virchow  (Deutsche  med.  Woch.,  Xov.  29. 
'88). 

Local  applications  of  various  prepara- 
tions of  mercury  are  no  less  toxic  than 
when  the  drug  is  taken  by  the  mouth. 
Case  of  girl,  aged  20  who  sprained  her 
wrist.  A  few  days  later  lymphangitis 
apparently  supervened,  for  which  mer- 
curial ointment  was  applied  and  rubbed 
into  some  cracks  on  the  hand.  An  hour 
after  the  inunction  the  patient  felt  ill. 
fainted,  and  vomited.  The  same  evening, 
there  was  much  swelling  of  the  hand  and 
of  the  arm  on  its  dorsal  aspect.  An  in- 
cision was  at  once  made  into  the  brawny 
and  gray-colored  tissues.  The  next  day. 
January  16th,  there  was  vomiting,  with 
tenesmus  and  slight  albuminuria.  Culti- 
vation experiments  were  negative.  On 
January  17th  the  vomiting  was  less  fre- 
quent, but  there  was  anuria.  The  stools 
were  blood-stained,  and  the  condition 
very  like  thai  of  dysentery.  There  was 
no  fever.  On  January  18th  severe  luvma- 
temesis  occurred.  Diarrhoea,  with  stools 
of  almost  pure  blood,  and  anuria  con- 
tinued. On  January  10th  there  were 
gangrenous  gingivitis  and  glossitis,  with 
moderate    salivation.      The  prostration 


MERCURY.    GENERAL  THERAPEUTICS. 


G09 


was  great,  but  the  mind  remained  clear. 
The  following  day  there  was  a  feeling 
of  weight,  and  then  paralysis,  in  the  ex- 
tremities, and  the  patient  died.  There 
were  small  haemorrhages  and  superficial 
sloughs  in  the  mucous  membrane  of  the 
lower  part  of  the  small  intestine  and 
the  characteristic  appearances  of  severe 
dysentery  in  the  large  intestine.  In  the 
kidneys  there  were  Avell-marked  necrotic 
changes  in  the  epithelium,  especially  of 
the  convoluted  tubes.  Sackur  (Berliner 
klin.  Woch.,  June  20,  '92). 

The  recommendation  of  preparations 
of  mercury  for  vaginal  douching  is  at- 
tended with  danger,  owing  to  the  large 
quantity  of  fluid  injected.  Eectal  in- 
jections are  still  more  dangerous,  owing 
to  the  rapidity  with  which  fluids  are  ab- 
sorbed. 

Case  of  mercurial  poisoning  from  the 
application  of  vaginal  tampons  wet  with 
a  solution  of  about  1  in  1200  of  corrosive 
sublimate  in  a  case  of  flooding  during 
pregnancy.  G.  T.  McKeough  (Canada 
Lancet,  vol.  xx,  p.  225,  '88). 

Literature  of  '96-'97-'98. 

Patient  injected  into  the  rectum  a  so- 
lution of  perchloride  of  mercury  (B.  P.) 
— 1  in  2000 — which  had  been  ordered  for 
the  preparation  of  a  vaginal  douche.  In 
half  an  hour  she  was  seized  with  cramp- 
like abdominal  pains,  and  a  little  later 
she  was  found  collapsed  and  pale,  with  a 
rapid  intermittent  and  weak  pulse,  the 
jaws  tightly  clenched,  the  eyes  dull  and 
anxious.  She  recovered  within  a  week, 
though  complaining  of  her  teeth  and 
gums.  Salivation  never  occurred.  Hall 
(Lancet,  Jan.  9,  '97). 

Treatment  of  Poisoning  by  Mercury. — 
Albumin  forms  an  insoluble  albuminate 
of  mercury;  hence  the  whites  of  several 
eggs  should  at  once  be  administered  to 
the  patient.  As  the  albuminate  is  liable 
to  be  disintegrated  after  a  certain  time, 
however,  the  stomach  should  be  evacu- 
ated soon  after  and  washed  out,  using 
the  stomach-pump.  As  soon  as  this  is 
done  more  white  of  egg  should  be  ad- 

4- 


ministered  and  left  in  situ.  If  none  can 
be  had,  wheat-flour  or  milk  may  be  used, 
the  former  being  given  with  a  little 
water,  just  enough  to  enable  it  to  reach 
the  stomach  promptly.  After  this  meas- 
ure the  symptoms  are  to  be  treated  on 
general  principles  as  they  appear. 

Three  drachms  of  yellow  oxide  of  mer- 
cury with  1  of  the  red,  accidentally  taken 
by  a  man,  produced  in  three  minutes 
violent  vomiting,  followed  by  diarrhoea. 
Milk  and  eggs  were  given,  and  the  man 
recovered.  Herbert  G.  Lee  (Brit.  Med. 
Jour.,  Sept.  28,  '89). 

General  Therapeutics  of  Mercury. 

Metallic  Mercury. — Mercury  itself  is 
used  in  the  following  forms: — 

Blue  Mass.  —  The  mercury  is  tritu- 
rated with  the  excipients  until  the  mer- 
curial globules  are  no  longer  visible 
under  a  microscope  magnifying  10  diam- 
eters. The  mass  thus  prepared  contains 
33  per  cent,  of  mercury.  The  dose  is 
from  1  to  10  grains.  The  familiar  "blue 
pill"  should  contain  3  grains,  but  this 
dose  is  sometimes  exceeded. 

Gray  Powder.  —  Mercury  with  chalk, 
or  hydrargyrum  cum  creta,  is  likewise  a 
fine  triturate,  but  it  contains  38  per  cent, 
of  mercury  and  57  per  cent,  of  prepared 
chalk.  Each  grain  of  gray  powder  con- 
tains about  V3  grain  of  mercury.  The 
dose  in  children  is  from  1/2  to  2  grains. 

Mercurial  or  blue  ointment  is  prepared 
by  triturating  mercury  with  lard  and 
suet  until  the  mercurial  globules  are  in- 
visible as  above.  It  contains  about  50 
per  cent,  of  metallic  mercury. 

Mercurial  plaster  is  a  combination  of 
metallic  mercury,  oleate  of  mercury  (see 
Oxides),  and  lead  plaster. 

Therapeutics. — Metallic  mercury  is 
mainly  employed  as  a  cathartic  in  the 
form  of  blue  pill.  As  such  it  is  an  ex- 
cellent agent  when  hepatic  torpor  is 

I  present,  though  it  sometimes  proves  irri- 
-39 


610  MERCURY. 

tating  to  the  intestinal  tract.  Nine 
grains,  or  three  3-grain  pills,  usually  give 
rise  to  little,  if  any,  griping.  If  this 
symptom  is  feared,  however,  a  little 
opium  may  he  added.  It  is  customary 
to  administer  a  saline  purgative  the  next 
day  to  enhance  the  effect  produced. 

When  a  series  of  symptoms  would  in- 
dicate a  bilious  state  of  the  system,  oc- 
curring in  persons  over  40,  especially 
women,  and  characterized  by  sleepless- 
ness, the  best  results  are  produced  by 
the  use  of  blue  pill.  This  acts  distinctly 
as  soporific.  W.  J.  Tyson  (Brit.  Med. 
Jour..  Jan.  31,  '91). 

Case  of  heart-failure  of  a  year's  stand- 
ing, with  increasing  severity  of  symp- 
toms, in  which  the  administration  of  blue 
mass  produced  the  most  excellent  results 
after  other  treatment  had  failed.  The 
drug  was  combined  with  digitalis  and 
sulphate  of  cinchonidine  in  the  same  pro- 
portion, 1  grain  of  each  in  every  pill. 
Three  pills  were  taken  daily.  Excellent 
results  obtained  with  the  same  combina- 
tion in  cases  of  general  oedema,  as  a  re- 
sult of  weak  heart  simply  or  of  organic- 
ally diseased  heart.  Regulated  diet  and 
hygiene  should  accompany  the  use  of  the 
remedies.  William  Pepper  (Univ.  Med. 
Mag.,  Jan.,  '90). 

Gray  powder,  or  mercury  with  chalk, 
possesses  much  the  same  properties  as 
blue  mass,  but  it  acts  more  mildly  and 
is,  therefore,  considerably  used  in  the 
treatment  of  children  suffering  from 
hepatic  atony  and  the  intestinal  ail- 
ments resulting  therefrom.  The  antacid 
power  of  the  chalk  adds  to  its  value  in 
the  treat  men  t  of  infantile  diarrhoea  with 
watery,  colorless  stools.  It  is  also  used 
in  infantile  syphilis  with  marked  success, 
especially  in  syphilitic  marasmus. 

Mercurial  ointment,  besides  its  well- 
known  value  in  the  treatment  of  syphilis 
(</.  v.),  is  also  employed  as  an  anti- 
phlogistic and  resolvent  in  inflammatory 
disorders  of  flu1  joints.  It  is  especially 
valuable  when  effusions  and  ankylosis 
are  feared  as  a  result  of  the  local  changes. 


X1TRATES. 

Its  antiphlogistic  properties  also  mani- 
fest themselves  in  inflammatory  proc- 
esses of  the  peritoneum,  and  it  is  often 
used  in  peritonitis.  The  same  may  be 
said  of  orchitis  and  epididymitis,  gland- 
ers, and  other  surgical  mycoses. 

Three  cases  of  human  glanders  treated 
by  gray  ointment.  The  first  case  died 
the  day  after  examination  by  the  author. 
The  other  two  received  the  infection  from 
the  first.  Abscesses  were  incised  and  dis- 
infected, and  friction  with  the  gray  oint- 
ment, 1  drachm  daily,  prescribed.  One 
and  one-half  ounces  were  used  in  the  one 
case,  and  G  l/2  ounces  in  the  other.  Cure 
resulted  in  both.  Gralevsky  (Wratsch, 
No.  25,  '93). 

Neapolitan  ointment  successfully  used 
in  treatment  of  malignant  pustule.  The 
ulcer  was  daily  washed  with  sublimate, 
carefully  wiped  with  cotton  soaked  in 
the  same  solution,  in  order  to  remove  all 
the  mortified  portions,  and  covered  with 
a  piece  of  linen  upon  which  the  ointment 
had  been  spread.  This  dressing  was  re- 
moved only  during  the  time  required  to 
wash  the  ulcer.  Definite  recovery  took 
place  within  four  or  five  weeks.  X. 
Vertepoff  (Medit.  Oboz..  Xo.  5.  '94). 

It  is  considerably  used  in  the  treat- 
ment of  pediculi,  or  other  parasites  of 
the  hairy  regions  of  the  body:  but,  as 
shown  by  Leidy,  any  fixed  or  volatile  oil 
or  even  a  bland  ointment  will  act  as 
effectually.  Hence  mercurial  ointment 
should  only  be  employed  after  trying 
the  less  dangerous  preparations.  If  the 
former  is  used,  care  should  be  taken  to 
avoid  salivation. 

Mercurial  plaster  may  be  used  in  the 
same  disorders  as  the  ointment  and  with 
the  same  objects  in  view.  It  is  especially 
valuable  in  the  treatment  of  splenic  en- 
largements of  malarial  origin.  It  is  also 
used  to  prevent  pitting  in  small-pox. 

Nitrates  of  Mercury. — The  nitrate  or 
pernitrate  of  mercury  i-  only  used  in  the 
preparation  of  a  solution  and  an  oint- 
ment. 

Solution  of  acid  nitrate  of  mercury,  the 


MERCURY.    CYANIDE.  qh 


liquor  hydrargyri  nitratis,  contains  about 
60  per  cent,  of  nitrate  of  mercury  and  11 
per  cent,  of  free  nitric  acid.  It  is  used 
as  a  caustic. 

Ointment  of  nitrate  of  mercury,  the 
unguentum  hydrargyri  nitratis,  or  citrine 
ointment,  contains  about  7  parts  of  mer- 
cury, 18  parts  of  nitric  acid,  and  75  parts 
of  lard-oil.  It  is  not  a  stable  prepara- 
tion and  should  be  freshly  prepared. 

Therapeutics. — The  solution  of  acid 
nitrate  of  mercury  is  a  very  active  caus- 
tic, instantly  penetrating  the  superficial 
tissues  and  especially  phagedenic  ulcera- 
tions. When,  therefore,  it  is  to  be  ap- 
plied, the  spot  to  be  touched  should  be 
surrounded  by  a  protective  covering  of 
vaselin,  and  a  glass  rod  used  for  the  ap- 
plication to  precisely  limit  the  amount 
employed.  Any  surplus  should  be  washed 
off.  It  is  extensively  used  for  the  de- 
struction of  syphilitic  sores,  benign  and 
malignant  neoplasms,  lupus,  epithelioma, 
noma,  nasvi,  moles,  warts,  etc. 

Acid  nitrate  of  mercury  has  been  em- 
ployed with  success  in  the  local  treatment 
of  nearly  all  unhealthy-looking  sores. 
The  preparation  of  the  British  Pharma- 
copoeia, which  is  a  syrupy  fluid,  is  used. 
The  acid  should  be  applied  with  a  brush, 
and  care  should  be  taken  not  to  use  too 
much  of  the  drug,  this  being  easily  pre- 
vented by  means  of  blotting-paper. 
Large  scars  can  thus  be  avoided,  espe- 
cially in  cases  of  acne  of  the  nose.  For 
large  ulcers,  patches  of  lupus,  and  for  the 
tubercles  and  patches  of  syphilitic  lupus, 
the  acid  can  be  applied  more  freely  ;  and 
in  these  cases  it  must  be  left  to  act  upon 
the  part  for  two  or  three  minutes  before 
the  blotting-paper  is  used.  Caution 
should  likewise  be  exercised  with  the 
drug,  as  indicated,  when  it  is  to  be  ap- 
plied to  the  mouth,  tongue,  cheek,  or 
throat.  Hutchinson  (Archives  of  Surg.. 
Oct..  '01). 

Literature  of  '96-'97-'98. 

Case  of  lupus  vulgaris  successfully 
treated  by  acid  nitrate  of  mercury.  The 


patient  had  suffered  from  lupus  vulgaris 
of  the  nose  for  more  than  four  years,  and 
had  undergone  many  scrapings.  Acid 
nitrate  of  mercury,  pure,  had  been  applied 
on  six  occasions  under  cocaine  anaes- 
thesia, with  the  result  that  the  parts  had 
healed  over  soundly,  no  trace  of  lupous 
tissue  being  now  visible.  Sheild  (Brit. 
Jour,  of  Dermat.,  Feb.,  '96). 

The  ointment  of  nitrate  of  mercury, 
citrine  ointment,  may  be  advantageously 
employed  for  deep-seated  inflammations 
limited  to  restricted  areas,  when  the 
superficial  tissues  are  intact.  It  may 
thus  be  used  to  abort  boils  and  felons. 

Ointment  of  the  nitrate  of  mercury 
successfully  used  as  an  abortifacient  of 
boils  and  felons.  In  treating  felons  the 
entire  finger  should  be  covered  with  the 
coating  of  the  ointment  about  V8  of  an 
inch  thick,  and  then  wrapped  with  a 
piece  of  thick  adhesive  plaster.  The 
dressing  should  remain  twenty-four 
hours,  after  which  no  further  treatment 
is  necessary.  R.  Kenner  (Med.  Rec,  Nov. 
10,  '88). 

When,  however,  the  ointment  of  ni- 
trate of  mercury  is  to  be  used  in  ulcera- 
tive processes,  for  which  it  is  employed 
as  an  active  stimulant,  it  should  be  di- 
luted by  the  addition  of  an  equal  quan- 
tity of  lard.  In  this  strength  it  is  espe- 
cially useful  in  chronic  disorders  of  the 
scalp,  and  is  occasionally  used  in  chronic 
eczema,  psoriasis,  and  other  cutaneous 
disorders  of  the  body,  but  only  when 
localized.  Its  application  over  large  sur- 
faces is  dangerous. 

Cyanide  of  Mercury. — Cyanide  of  mer- 
cury, hydrargyrum  cyanatum,  occurs  in 
whitish  crystals  devoid  of  odor,  but  of 
metallic,  bitter  taste.  It  is  principally  , 
used  as  a  local  antiseptic  in  1  to  10,000 
solution.  It  is  very  poisonous.  The 
dose  is  V32  10  Vie  grain. 

Therapeutics. — The  oxycyanide  of 
mercury  has  been  highly  lauded  as  an 
antiseptic  in  surgery.    It  is  well  tolerated 
!  by  the  tissues,  and  is  thought  to  be  spe- 


612 


MERCURY.  CYANIDE. 


cially  applicable  to  suppurating  surfaces 
or  to  mucous  membranes,  as  the  con- 
junctiva, to  render  them  aseptic. 

As  a  disinfectant,  especially  when  me- 
tallic instruments  are  to  be  used,  oxy- 
cyanide  of  mercury  is  considered  the  best 
substance,  since  it  does  not  in  any  way 
affect  the  latter,  not  even  the  edge  of 
cutting  instruments.  A  3-per-cent.  solu- 
tion corresponds  to  a  2-per-cent.  solution 
of  corrosive  sublimate,  but  a  1  to  10,000 
solution  has  been  found  efncious  for  ex- 
ternal uses.  Monod  and  Malgaigne  em- 
ployed, it  successfully  in  hospital  and 
private  work  and  found  that  it  possessed 
all  the  qualities  of  corrosive  sublimate. 
It  prevents  the  growth  of  cultures  and 
kills  developed  cultures,  including  the 
bacillus  coli,  the  bacillus  pyocyaneus, 
streptococci,  etc.  The  drug  being  ex- 
ceedingly toxic,  they  never  use  large 
quantities  at  a  time  and  avoid  using  it 
for  washing  out  cavities. 

Oxy cyanide  of  mercury  in  5  per  1000 
solution  displays  in  laboratory  experi- 
ments an  antiseptic  potency  always  equal 
to  and  often  greater  than  that  of  1  to 
1000  sublimate  solution.  It  has  no  dis- 
advantages other  than  those  possessed 
by  corrosive  sublimate,  and  it  has  the 
special  advantage  of  not  affecting  either 
the  hands  or  the  instruments  of  the  sur- 
geon. C.  Monod  (Le  Prog.  M§d.,  Oct.  20. 
'95). 

Cyanide  of  mercury,  highly  recom- 
mended as  an  antiseptic  for  use  by  ocu- 
lists, is  efficient,  though  non-irritating. 
The  micrococcus  pyogenes  aureus  is 
present  in  apparently  perfectly  healthy 
conjunctival  sacs.  The  operation  for 
cataract  can  be  performed  suecessfully 
without  troublesome  complications.  Oxy- 
cyanide  of  mercury  is  a  powerful  anti- 
septic. Fourteen  patients  were  treated 
by  means  of  irrigation  with  a  solution 
of  the  drug  in  the  proportion  of  1  part  to 
1500  of  water.  On  subsequently  sub- 
mitting the  conjunctival  mucus  to  sys- 
tematic culture,  the  tubes  only  re- 
mained sterile  in  20  per  cent,  of  the  1 


cases.  The  other  tubes  contained  vari- 
ous microbes,  especially  the  pyogenes 
aureus.  Further  experiments  proved 
that  the  eyes  could  only  be  rendered 
thoroughly  aseptic  by  eye-douches,  re- 
peated every  few  minutes  for  at  least 
three  days;  the  oxycyanide  is  superior 
to  solutions  of  the  bichloride,  and  is 
better  borne  by  the  conjunctiva.  Chibret 
(Recueil  d'Ophtal.,  p.  294,  '89). 

Literature  of  '96-'97-'98. 

Preparations  of  mercuric  cyanide  may 
usefully  be  prescribed  in  the  form  of 
fomentations  and  collyria.  A  formula 
which  is  of  daily  use  in  cases  of  progress- 
ive choroidal  atrophies  in  myopes  and  in 
disseminated  forms  of  choroiditis  in 
gouty  persons  is  as  follows:  — 

Rc  Hydrochlorate     of    cocaine,     3  3/4 
grains. 

Cyanide  of  mercury,  4 1/2  grains. 
Cherry-laurel  water,  6  V4  drachms. 
Distilled  water,  8  V?  ounces. — M. 
This  same  lotion  may  be  used  in  certain 
forms  of  severe  exudative  and  plastic 
choroiditis,  as  a  subconjunctival  injec- 
tion.   Galezowski  (Recueil  d'Ophtal.,  No. 
12,  '96). 

It  has  been  recommended  as  a  safe 
agent  for  hypodermic  use,  but  is  an  ex- 
tremely dangerous  remedy  for  intrav- 
enous injections. 

Cyanide  of  mercury  recommended  in  1 
to  2  solution  for  hypodermic  use:  the 
pain  which  it  produces  i-  insignificant. 
In  this  respect  it  is  superior  to  the  pep- 
tonate.  J.  Roussel  (Jour,  de  Med.  de 
Paris.  Mar.  25,  '88). 

Injections  of  1-per-cent.  solution  of 
oxycyanide  of  mercury  employed  in  the 
treatment  of  syphilitic  conditions.  In- 
jections are  well  borne,  little  painful, 
and.  used  in  over  1000  cases,  has  never 
caused  untoward  effects.  Six  or  eight  in- 
jections are  equivalent  to  an  energetic 
treatment  by  means  of  frictions.  Chibret 
(La  Sem.  Med..  Apr.,  '90). 

Internally  it  has  been  administered 
for  syphilis  and  diphtheria,  but  in  both 
of  these  diseases  other  remedial  agents 
are  to  be  preferred. 


MERCURY. 

Great  success  obtained  with  cyanide  of 
mercury  in  diphtheria;  1400  cases  have 
been  treated  with  it,  with  a  death-rate 
of  only  4.9  per  cent.  A  teaspoonful  of  a 
1  in  10,000  solution  is  given  every  quar- 
ter to  one  hour,  according  to  the  age  of 
the  child.  H.  Sellden  (Wiener  med. 
Presse.,  Apr.  8,  '88). 

Oxides  of  Mercury. — YellovV  Oxide. 
— The  yellow  oxide  of  mercury,  hydrar- 
gyri oxidum  flavum,  occurs  as  a  yellow, 
fine,  amorphous  powder  devoid  of  odor, 
but  metallic  to  the  taste.  It  is  insoluble 
in  water,  and  becomes  darker  on  ex- 
posure to  light.  It  is  too  irritating  for 
internal  administration  and  is  mainly 
employed  to  prepare  the 

Ointment  of  yellow  oxide  of  mercury 
or  unguentum  hydrargyri  oxidi  flavi, 
which  contains  10  per  cent,  of  the  oxide. 
This  is  too  strong  for  use  in  ophthalmic 
practice,  however,  and  is  usually  reduced 
by  the  addition  of  lard,  lanolin,  etc. 

Literature  of  '96-'97-'98. 

Proper  way  of  preparing  the  yellow- 
oxide-of-mercury  ointment  for  use  in 
ophthalmological  practice.  To  the  re- 
quired amount  of  powder  in  impalpable 
form  on  a  clean  glass  or  porcelain  slab, 
add  a  few  drops  of  any  bland  noh-irri- 
tating  fixed  oil,  and  mix  well  with  a  clean 
spatula ;  to  this  slowly  add  the  necessary 
petrolatum.  The  following  prescription 
in  the  hands  of  a  competent  pharmacist 
will  be  entirely  satisfactory:  — 

I£  Olei  ricini,  4  drops. 

Hydrarg.  oxidi  flavi,  3  grains. 
Misce  et  adde:  — 

Petrolati,  2  to  4  drachms. 
The  mass  is  so  thoroughly  homogeneous  j 
that  not  until  it  is  kept  for  a  long  while 
will  the  mercury  gravitate  to  the  bottom. 
T.  E.  Mitchell  (Ophth.  Rec,  Feb.,  '98). 

It  is  also  used  to  prepare  the  oleate  of 
mercury,  or  oleatum  hydrargyri,  which 
contains  2  per  cent,  of  the  yellow  oxide 
and  8  per  cent,  of  oleic  acid.  It  is  used 
in  preference  to  blue  ointment  by  many 
practitioners. 


.    OXIDES.  613 

The  red  oxide  of  mercury,  or  hydrar- 
gyri oxidum  rubrum,  occurs  in  the  form 
of  orange-red  crystals,  which,  though 
carefully  pulverized,  always  contain  irri- 
tating particles.  It  is  insoluble  in  water, 
and  is  not  used  internally.  It  is  em- 
ployed to  prepare  an  ointment,  the 

Ointment  of  red  oxide  of  mercury,  but 
this  has  been  advantageously  replaced 
by  the  ointment  of  the  yellow  oxide, 
owing  to  the  finer  grain  of  the  powder 
obtained  from  the  latter. 

Black  wash  and  yellow  wash,  two  offi- 
cial preparations  considerably  used  as 
stimulants,  depend  for  their  virtues  upon 
the  black  and  yellow  oxides  formed. 
Black  wash  contains  1  drachm  of  calomel 
to  a  pint  of  lime-water;  while  yellow 
wash  contains  1/2  drachm  of  corrosive 
sublimate  to  a  pint  of  lime-water. 

Therapeutics.  —  The  yellow  oxide 
enjoys  the  confidence  of  ophthalmolo- 
gists in  the  treatment  of  blepharitis  and 
conjunctivitis,  owing  to  its  antiphlogistic 
and  alterative  properties.  In  the  acute 
form  of  the  latter  disorder  an  ointment 
containing  3  to  4  grains  of  the  yellow 
oxide  to  the  ounce  is  sufficiently  strong, 
while  disorders  of  the  lids  usually  re- 
quire a  preparation  four  times  that 
strength.  The  ointment  should  not, 
however,  be  allowed  to  come  into  con- 
tact with  the  conjunctiva.  Corneal 
opacities  and  ulcers  are  also  favorably 
influenced  by  the  continued  application 
of  an  ointment  of  yellow  oxide  of  mer- 
cury. 

Literature  of  '96-'97-'98. 

Corneal  ulcer  successfully  treated  by 
the  simple  application  of  a  salve  of  the 
yellow  oxide  of  mercury,  followed  by  an 
occlusive  dressing.  Sicherer  (Rev.  Gen. 
d'Ophtal.,  Nov.,  '96). 

In  affections  of  the  skin  it  has  been 
u<v(]  with  advantage  in  eczema  and  acne. 


G14  MERCURY. 

Erythematous  pruritus  of  the  anus  is 

quickly  arrested  by  its  use. 

Valuable  ointment  for  anal  pruritus 
is  composed  of  GO  grains  of  red  oxide  of 
mercury  with  450  of  vaselin.  Morain 
(Rev.  Inter,  de  Med.,  July,  '95). 

Literature  of  '96-'97-'98. 

A  very  useful  combination  when  much 
pustulation  exists  in  acne  is:  — 

Ungt.  hydrarg.  oxid.  rub.,  3  drachms. 

Ungt.  sulphuris,  6  drachms. 

Ungt.  zinc,  oxid.,  ad  2  ounces. — M. 
G.  T.  Elliot  (Post-graduate,  Oct.,  '96). 

The  red  oxide  is  mainly  used  to  stimu- 
late obstinate  ulcerative  processes,  such 
as  those  occurring  in  venereal  disorders. 
It  is  also  employed  in  parasitic  diseases 
of  the  skin. 

Varicose  ulcers  of  legs  successfully 
treated  with  ointment  of  the  red  oxide  of 
mercury.  Officinal  ointment  too  strong 
( 1  part  of  the  red  oxide  of  mercury  to  9 
of  vaselin)  :  so  that  it  was  mixed  with 
1  to  2  parts  of  vaselin.  Influence  upon 
suppurating  wounds  was  apparent  in  a 
short  time.  First  day,  patient  complains 
of  violent  pains,  which  by  the  third  have 
entirely  or  nearly  disappeared.  Dressing 
should  be  renewed  once  a  day  and  the 
salve  be  spread  upon  a  piece  of  cloth  to 
the  thickness  of  a  knife-blade;  a  flannel 
or  small  bandage  may  be  used  to  wrap 
the  extremity.  Rest  in  bed  will  acceler- 
ate the  healing  process.  H.  Ranges 
(Munch,  med.  YYoch.,  No.  48,  '94). 

Black  and  yellow  wash  are  also  mainly 
employed  to  stimulate  chancres  and 
syphilitic  ulcers,  the  yellow  wash  being 
far  more  potent  than  the  black.  The 
latter  is  sometimes  used  in  eczema. 

The  oleate  of  mercury  is  often  sub- 
stituted for  a  much  more  cleanly  agent, 
blue  ointment.  The  irritating  action  of 
the  red  oxide  should  be  borne  in  mind, 
however,  and  it  should  be  rubbed  into 
the  tissues  in  somewhat  smaller  quanti- 
ties and  with  less  rapidity.  It  i>  also 
employed  in  parasitic  skin  disorders,  hav-  I 


IODIDES. 

ing  replaced  gray  ointment  in  many  of 
these,  especially  tinea  tonsurans,  pedic- 
uli  corporis,  and  sycosis. 

Iodides  of  Mercury. — The  red  iodide 
or  biniodide  of  mercury,  or  hydrargyri 
iodidum  rubrum,  is  a  scarlet-red  powder 
having  no  odor  or  taste.  It  is  practically 
insoluble  in  water,  and  slightly  soluble 
in  alcohol.  The  dose  is  from  1/:{2  to  1/8 
grain,  administered  in  pill  form. 

Albuminous  solutions  of  the  biniodide 
remain  clear  for  days,  whereas  with  the 
bichloride  of  mercury  an  insoluble  pre- 
cipitate is  formed.  The  solution  for  use 
is  to  be  made  witli  the  iodide  of  potash. 
A  jar  containing  bichloride  solution  and 
blood  showed,  at  the  end  of  six  week-,  a 
few  bacilli  and  micrococci,  and  its  surface 
was  covered  with  penicillium  glaucum. 
while  a  similar  jar  containing  biniodide 
solution  was  perfectly  free  from  any 
change.  G.  Sims  Woodhead  (Proc.  Royal 
Soc.  of  Edinburgh,  '89). 

An  albuminous  precipitate  is  always 
produced  by  the  biniodide  of  mercury. 
The  tartaric-acid  solution  of  the  bichlo- 
ride of  mercury,  as  originally  proposed  by 
Laplace,  is  the  only  antiseptic  prepara- 
tion of  mercury  which  will  not  act  in  this 
way.   Hare  (Univ.  Med.  Mag.,  Sept.,  '89). 

The  solution  of  arsenic  and  iodide  of 
mercury,  the  liquor  arsenici  et  hydrar- 
gyri iodidi,  Donovan's  solution,  contains 
1  per  cent,  each  of  the  red  iodide  of  mer- 
cury and  iodide  of  arsenic  in  distilled 
water.  The  dose  is  from  3  to  10  drops, 
largely  diluted. 

The  green  or  yellow  iodide  of  mercury, 
or  protiodide,  the  hydrargyri  iodidum 
flavum,  is  a  yellowish-green,  amorphous 
powder,  devoid  of  odor  or  taste.  It  is 
decomposed  by  light.  The  dose  is  from 
Vs  to  V4  grain. 

Therapeutics.  —  The  red  iodide  of 
mercury  is  principally  used  in  the  treat- 
ment of  syphilis  (see  SYPHILIS  in  vol- 
ume vi).  but  it  has  also  been  found  use- 
ful in  various  other  disorders  and  as  an 


MERCURY. 

antiseptic  in  surgery,  and  in  infectious 
disorders. 

Biniodide  of  mercury  dissolved  in  a 
solution  of  sodium  iodide  does  not  pro- 
duce the  unfavorable  conditions  that  fol- 
low the  use  of  the  bichloride.  Hanbury 
Frere  (N.  Y.  Med.  Jour.,  July  28,  '94). 

Sodic-iodide  solution  of  mercury  binio- 
dide 1  to  2000  used  for  all  amputation- 
flaps  and  recent  wounds.  Union  is  se- 
cured more  firmly  and  rapidly  than  with 
carbolic-acid  dressings.  The  firm  and 
rapid  union  being  attributed  to  the  solu- 
tion and  removal  of  the  two  layers  of 
effused  fibrin,  on  the  flat  surfaces,  by  the 
fibrin-solvent  sodic-iodide  vehicle  for  the 
antiseptic  agent,  It  has  the  advantage 
of  being  non-irritant,  and  it  is  rapidly 
eliminated  by  the  kidneys.  C.  R.  Illing- 
worth  (Satellite  of  the  Annual,  Jan.,  '92). 

Mercury  biniodide  strongly  recom- 
mended for  washing  out  the  abdominal 
cavity  (in  laparotomy),  pleura  (empy- 
ema), cerebral  meninges  (traumatic  in- 
juries), and  synovial  membranes  (sup- 
purative arthritis).  No  untoward  effects 
ever  seen.  P.  K.  Bolshesolsky  (Proc.  of 
the  Arkangelsk  Med.  Soc,  v.  ii,  p.  19,  '94). 

Biniodide  of  mercury  used  in  C  cases 
of  labor  in  which  injections  were  indi- 
cated, in  all  of  which  the  patients  did 
well.  A  1  to  4000  solution  was  used  three 
to  four  times  daily.  It  also  acted  well 
in  a  case  of  abdominal  abscess  intercur- 
rent with  typhoid  fever,  in  a  case  of 
double  laceration  of  the  cervix,  in  abscess 
of  the  foot,  in  1  of  the  axilla,  and  3  cases 
of  carbuncle.  Enveloping  the  chest  in  a 
layer  of  biniodide-of-mercury  wool  re- 
lieves the  pain  in  pulmonary  disorders. 
Eugene  P.  Bernardy  (Trans.  Phila.  Co. 
Med.  Soc,  Jan.  25,  '89). 

In  the  infectious  fevers  biniodide  of 
mercury  has  been  found  of  value  both 
as  a  local  antiseptic  and  as  a  general 
germicide. 

Scarlet  fever  abated  in  five  instances 
by  the  internal  and  external  use  of  the 
biniodide  of  mercury.  The  disease  has 
been  prevented  from  spreading  by  paint- 
ing the  throat,  with  1  in  500  solution 
every  four  hours.  In  the  cases  reported 
the  following  formula  was  used:  — 


IODIDES.  615 

I£  Hyd.  bichlor.,  G  drachms. 
Potass,  iod.,  15  grains. 
Sp.  am.  co.,  1  drachm. 
Syrup.,  l/2  ounce. 
Aq.,  6  ounces. 

M.  Sig. :  Half  an  ounce  every  second 
hour. 

This  was  used  in  a  child  9  years  old. 
For  local  application  the  solution  varied 
from  1  in  2000  to  1  in  500,  to  be  used  in 
the  form  of  a  spray  or  by  painting  with 
a  camel-hair  brush.  C.  R.  Illingworth 
(Provincial  Med.  Jour.,  Jan.  1,  '90). 

Biniodide  of  mercury  successfully  used 
in  the  treatment  of  diphtheria  and  ty- 
phoid fever:  the  drug  is  an  antiseptic 
and  germicide  of  great  value.  For  the 
first  disease  this  formula  was  em- 
ployed: biniodide  of  mercury,  2  grains; 
saccharated  pepsin,  3  drachms.  The 
powder  is  used  as  a  local  solvent  and 
germicide,  placing  a  quantity  of  it,  pro- 
portionate to  the  age  of  the  patient  and 
the  severity  of  the  symptoms,  on  the 
tongue  every  hour.  In  addition  to  this 
treatment  may  be  employed  through  in- 
sufflation, a  powder  containing  2  grains 
of  the  biniodide  of  mercury  and  20  grains 
of  trypsin,  to  be  applied  every  four  hours. 

The  administration  of  the  remedy  is 
regulated,  then,  by  the  gradual  improve- 
ment. The  efficacy  of  the  drug  was  most 
satisfactory  in  laryngeal  cases.  In  cases 
of  typhoid  fever,  especially  if  the  treat- 
ment was  instituted  early,  the  drug  pro- 
duced satisfactory  results.  Disease  was 
abated  by  employing  the  drug  in  the  pro- 
dromic  period.  For  this  purpose,  as  for 
the  treatment  of  the  disease  when  pres- 
ent, a  mixture  of  Vio  to  V12  grain,  and  10 
grains  of  saccharated  pepsin  was  given 
every  four  or  six  hours.  B.  F.  Ackley 
(Pittsburgh  Med.  Review,  June,  '90). 

Protiodide  of  mercury  in  1/2-grain  pills 
recommended  for  typhoid  fever.  Heim- 
street  (Jour.  Amer.  Med.  Assoc.,  Apr.  17, 
'97). 

Biniodide  of  mercury  precipitating 
t}Totoxicon  in  liquids,  it  has  been  rec- 
ommended as  an  antidote  in  ptomaine 
poisoning. 

The  biniodide  of  mercury  precipitates 
and   renders  inert  the  milk  or  cheese 


616  MERCURY. 

ptomaine:  tyrotoxicon.  Luff  (Lancet, 
Dee.  20,  '91). 

Employment  of  the  biniodide  of  mer- 
cury recommended  in  cases  of  ptomaine 
poisoning.  A.  Hanbury  Frere  (Provincial 
Med.  Jour.,  Mar.,  '92). 

The  green  or  yellow  iodide  is  mainly 
employed  in  syphilis  (q.  v.). 

The  solution  of  arsenic  and  mercuric 
iodide  is  much  esteemed  in  the  treatment 
of  chronic  disorders  of  the  skin:  leprosy, 
lupus,  etc.  It  is  also  advantageous  in 
chronic  gout  and  rheumatism  as  a  gen- 
eral alterative  and  tonic. 

Chlorides  of  Mercury. — The  mild  mer- 
curous  chloride,  hydrargyri  chloridum 
mite,  calomel,  is  a  tasteless,  white,  im- 
palpable powder,  insoluble  in  water  and 
alcohol.  Its  dose  varies  from  1/4  grain 
to  10  grains  or  even  much  more,  accord- 
ing to  the  disorder  treated. 

The  mercuric  chloride,  hydrargyri 
chloridum  corrosivum,  or  corrosive  sub- 
limate, is  prepared  by  subliming  the 
bisulphate  of  mercury  with  chloride  of 
sodium.  It  occurs  in  the  form  of  trans- 
parent, whitish  crystals,  of  a  metallic, 
acid  taste,  and  is  soluble  in  sixteen  parts 
of  cold  and  two  parts  of  boiling  water, 
and  in  three  parts  of  alcohol.  Its  dose 
varies  from  1/100  to  1/8  grain. 

Ordinary  water  causes  an  immediate 
decomposition  of  bichloride  of  mercury; 
this  decomposition  steadily  continues 
under  the  influence  of  air  and  light.  This 
decomposition  ceases  or  becomes  arrested 
when  the  air  and  light  are  excluded. 
Solutions  of  bichloride  of  mercury  made 
in  distilled  water  undergo  only  trifling 
decompositions,  even  when  exposed  to 
air  and  light.  Burcker  (Archives  de  Med. 
et  de  Pharm.  Milit,  Apr.,  "9o). 

Sublimate  solutions  should  be  kept  in 
brownish-yellow  bottles,  in  order  to  pre- 
vent the  decomposition  which  ordinary 
light  gradually  produces.  H.  Michaelis 
(Zeits.  fur  Hyg.,  Aug.  23,  '88). 

Bichloride  undergoes  chemical  change 
when  in  contact  with  organic  matter,  and 
is  immediately   converted   by  albumin 


CHLORIDES. 

into  an  insoluble  albuminate.  A  small 
quantity  is  soluble  in  excess  of  albumin, 
but  is  likely  to  be  at  once  decomposed, 
in  masses  of  excreta,  into  the  insoluble 
sulphide  by  the  sulphuretted  hydrogen 
present.  W.  B.  Hills  (Boston  Med.  and 
Surg.  Jour.,  Feb.  21,  '89). 

Therapeutics  of  Calomel. — As  a 
purgative,  calomel  is  still  considerably 
employed,  though  slow  in  action  and 
occasionally  unreliable.  The  possibility 
of  retention  under  such  circumstances 
renders  mercurial  absorption  possible 
when  a  large  dose  is  administered,  and 
it  is  always  prudent  to  administer  a 
saline  the  next  morning  or  to  give 
another  purgative  at  the  same  time — a 
poor  recommendation  for  the  primary 
drug.  The  compound  cathartic  pill  is 
based  upon  this  principle.  Eecent  labors 
have  severely  shaken  the  general  belief 
that  calomel  increases  the  flow  of  bile, 
and  tend  to  confirm  the  view  that  as  a 
true  purgative  there  are  many  agents, 
especially  podophyllin,  that  are  prefer- 
able. Its  germicidal  action  may  render 
it  useful,  however,  in  the  presence  of 
infectious  processes.  In  diphtheria,  for 
instance,  it  is  useful  and  it  will  some- 
times check  the  disease  when  adminis- 
tered, but  this  can  hardly  be  credited  to 
its  merits  as  a  purgative. 

Literature  of  W-'M-'dS. 

Effect  of  calomel  on  the  secretion  of 
bile  as  the  result  of  experimental  research 
on  dogs  with  biliary  fistulas.  Oil  has  a 
negative  effect  on  the  secretion  of  bile, 
calomel  a  decided  inhibitory  effect,  and 
salicylate  of  sodium,  while  it  increases 
the  quantity  of  bile  secreted,  lowers 
the  density:  the  salts,  etc.,  are  reduced 
below  the  normal  amount.  The  only  ac- 
tive cholagogue  is  bile  itself,  the  ingestion 
of  which  is  always  followed  by  a  consider- 
able hypersecretion  of  bile.  Boy  on  and 
Dufour  (Presse  Med..  Oct,  13.  '97). 

Purgative  effects  are  obtained  with 
i  more  certainty  and  witli  no  danger  of 


MERCURY. 

ptyalism  when  very  small  doses,  1/8  to 
1/2  grain,  are  administered  every  half- 
hour  until  3  grains  are  taken.  All  the 
mercury  thus  ingested  undergoes  trans- 
formation into  the  purgative  salt  in  the 
intestinal  tract,  and  there  is  no  surplus 
to  awaken  toxic  symptoms  later  on. 

In  the  albuminuria  of  pregnancy,  if 
there  is  need  of  a  purgative,  it  is  better 
to  prescribe  calomel.  Huchard  (Jour,  des 
Prat.,  No.  1,  '95). 

Large  doses  of  calomel  have  been  rec- 
ommended in  the  early  stages  of  acute 
febrile  diseases,  pleurisy,  pneumonia,  yel- 
low fever,  and  even  in  such  affections 
as  cholera.  More  clinical  experience  is 
necessary  to  confirm  this  view,  but  it 
seems  to  be  in  accord  with  data  upon 
the  physiological  action  of  the  remedy. 

The  same  indications  apply  to  the  use 
of  calomel  in  jaundice,  or  biliousness 
due  to  exposure  to  cold,  the  action  being 
probably  derivative  and  germicidal,  to 
say  nothing  of  stimulating  powers  which 
minute  doses  of  mercury  are  known  to 
possess. 

In  children  very  small  doses  thus  be- 
come extremely  valuable  when  general 
inaptitude  is  associated  with  "heavy" 
breath  and  usually  ill-smelling  stools. 
Four  doses  of  1/25  grain  every  half- 
hour  until  five  doses  are  taken,  repeated 
in  four  or  five  days  if  needed,  sometimes 
changes  the  entire  aspect  of  the  child. 
It  is  best  administered  thoroughly  mixed 
with  a  little  sugar,  the  powder  being 
merely  placed  on  the  tongue.  The  tonic 
action  of  the  remedy  plays  an  important 
role  here — provided  only  minute  doses 
are  adhered  to. 

In  infantile  diarrhoea  this  treatment  is 
invaluable,  but  1/20  grain  should  be  ad- 
ministered every  three  hours.  As  an 
anthelmintic  it  may  also  be  used  with 
considerable  advantage. 

Diphtheria. — In  this  disease  calomel 
may  be   employed   advantageously  in 


CHLORIDES.  617 

three  ways.   As  a  preventive  it  has  been 
highly  recommended  by  Daly,  of  Pitts- 
burgh.  It  is  to  be  administered  in  small 
doses  until  its  action  upon  the  intestinal 
tract  is  shown  by  characteristic  stools. 
Calomel  is  valuable  in  diphtheria;  it 
is  the  best  remedy  we  possess  for  promot- 
ing absorption,  and  is  a  safe  and  efficient 
germicide.    Of  thirty  children  treated  by 
this  method  only  two  cases  were  fatal. 
G.  B.  Fowler  (Obstet.  Gaz.,  Jan.,  '88). 

Fumigations  are  also  valuable,  the 
calomel  being  volatilized  under  a  tent 
formed  by  sheets  arranged  over  a  frame 
inclosing  the  bed.  It  tends  to  soften  the 
soft  membrane  to  facilitate  its  detach- 
ment, while  acting  as  a  germicide. 

Diphtheria  treated  by  mercurial  fumi- 
gations. For  a  child  of  8  to  10  years  40 
to  60  grains  of  calomel  are  volatilized 
under  a  suitable  tent  or  canopy,  this 
being  kept  over  the  child  20  minutes. 
This  procedure  is  repeated  every  2  to  3 
hours  during  the  first  day.  The  process 
is  continued  at  the  rate  of  2  to  3  times  a 
day  for  a  week  if  the  cough  tightens 
again.  The  lamp  should  be  powerful 
enough  to  volatilize  rapidly,  so  that  the 
temperature  under  the  canopy  may  not 
be  unpleasantly  elevated.  J.  Corbin 
(N.  Y.  Med.  Jour.,  vol.  xlvii,  p.  261,  '88). 

Calomel  fumigations  of  value  in  croup. 
The  indications  of  this  treatment  are  re- 
cession of  the  suprasternal  notch  during 
inspiration,  with  retraction  of  the  infra- 
thoracic  walls,  stridulous  breathing, 
hoarseness  or  aphonia  at  times,  and  liyid- 
ity  of  the  surface  resulting  from  the  de- 
ficient oxygenation  of  the  blood.  The 
amount  of  the  mercurial  salt  to  be  vapor- 
ized varies  from  5  to  20  grains,  repeated 
at  intervals  varying  from  one-half  to  two 
or  three  hours,  according  to  the  severity 
of  the  symptoms — in  the  average  case  15 
grains  hourly.  The  patient  is  to  be 
kept  in  the  vapor-saturated  atmosphere, 
within  a  tent,  for  a  period  varying  from 
ten  minutes  to  half  an  hour.  Fruitnight 
(Arch,  of  Fed.,  June,  '95). 

All  the  mercurial  preparations  possess 
diuretic  properties,  but  these  are  espe- 
cially marked  when  calomel  is  employed. 


018  MERCURY. 

The  increase  of  urine  may  range  from 
a  few  ounces  to  as  much  as  370  ounces 
(Jendrassik).  When  administered  in 
moderate  doses  repeated  every  three  or 
four  hours,  the  diuretic  action  appears 
early  in  some  cases  and  only  after  four 
or  five  days  in  others.  According  to 
Lipari,  tolerance  for  calomel  is  greatest 
in  those  cases  in  which  diuretic  action 
is  most  rapidly  produced.  On  the  con- 
trary, the  tolerance  is  least  in  those  in- 
stances where  the  production  of  diuresis 
is  retarded.  The  main  untoward  feature 
of  its  use  is  the  marked  tendency  to  cause 
ptyalism  and  other  manifestations  of 
mercurial  intoxication.  Hence  the  pa- 
tients should  he  carefully  watched.  Cal- 
omel is  especially  efficacious  in  dropsical 
conditions  of  cardiac  origin. 

Six  doses  of  1  1/2  grains  each  may  be 
given  during  the  day,  one  every  three 
hours.  In  cases  in  which  there  is  a 
comparatively  small  cardiac  lesion  with 
marked  dyspnoea  and  hypertrophy  or 
dilatation,  with  albuminuria,  oedema, 
and  ascites,  this  treatment  is  useful. 
After  the  first  few  doses  have  been  given, 
as  a  rule,  an  increase  in  diuresis  is  estab- 
lished, and  on  the  second  or  third  day 
quite  copious  evacuations  of  the  bowels 
take  place.  There  is  marked  improve- 
ment in  all  the  symptoms,  cardiac  and 
otherwise.  Even  when  the  calomel  is 
no  longer  administered  these  good  results 
persist  for  from  twenty-four  to  forty- 
eight  hours.  In  order  to  prevent  ex- 
cessive salivation,  or  to  relieve  it  when 
already  produced,  the  following  mouth- 
wash is  used: — 

IJ  Chlorate  of  potas.,  2  1/2  drachms. 

Tannic  acid,  4  grains. 

Distilled  water,  10  ounces. — M. 
The  calomel  does  good  by  relieving 
the  congestion  of  the  liver  and  the  renal 
circulation,  thus  indirectly  reducing  the 
resistance  to  the  heart  produced  by  arte- 


CHLORIDES. 

rial  pressure.  At  the  same  time  an  ab- 
solute milk  diet  is  ordered.  Of  107  cases 
of  grave  cardiac  disorder  with  distressing 
symptoms  of  failure  of  the  heart,  treated 
in  this  manner  by  Moraldescu  there  were 
14  deaths:  2  died  of  pneumonia  after 
the  heart-symptoms  were  relieved;  3 
died  before  the  treatment  had  sufficient 
opportunity  to  be  tried;  the  remaining 
9  were  of  advanced  years  and  the  dis- 
ease was  also  far  advanced. 

Mercury  is  especially  of  value  when 
there  is  no  concomitant  renal  or  he- 
patic disorder,  and  hurtful,  according  to 
Huchard,  when  the  urine  contains  albu- 
min. 

Calomel  is  a  very  valuable  diuretic  ill 
the  dropsy  of  heart  disease,  but  useless  in 
that  depending  on  renal  or  hepatic  affec- 
tions. Two  and  one-half  grains  are  given 
four  times  a  clay  until  ten  doses  are 
taken.  The  increase  in  the  secretion  of 
urine  does  not  appear  until  the  third  or 
fourth  day.  Should  no  result  follow  in 
four  days  the  treatment  is  stopped,  to  be 
recommenced  after  eight  days.  If  suc- 
cessful on  the  first  trial,  a  second  course 
of  ten  doses  is  carried  out  after  two 
to  four  weeks.  H.  Nothnagel  (Ther. 
Monats.j  May,  '88). 

In  a  desperate  case  of  mitral  regurgita- 
tion, accompanied  with  great  dyspnoea, 
oedema,  constant  gastric  pain,  and  scanty 
urine,  digitalis  had  signally  failed  to  give 
relief.  Excellent  result-  were  obtained 
from  the  use  of  calomel  in  10-grain  doses 
at  a  time,  administered  on  alternate 
nights.  All  the  distressing  symptoms  dis- 
appeared gradually,  and  in  fifteen  days 
the  patient  was  in  comparatively  good 
health.  William  Carter  (Liverpool 
Medico-Chir.  Jour..  Jan.,  '91). 

The  best  results  from  mercury  are  seen 
in  oedema  resulting  from  cardiac  failure. 
Diseases  of  the  kidneys  limit  or  entirely 
abolish  the  diuretic  action.  It  is  impor- 
tant that  full  doses  be  given,  as  small 
amounts  are  not  diuretic.  For  the  first 
two  days  the  secretion  of  urine  is  di- 
minished, but  afterward  it  is  augmented. 
Action  of  the  drug  is  due  to  the  irrita- 
tion  which    it    produces   while  passing 


MERCURY. 

through  the  kidneys.  W.  Bieganski 
(Archiv  f.  klin.  Med.,  Sept.,  '88). 

Calomel  is  useless  in  cardiac  diseases 
complicated  with  cirrhosis,  and  hurtful 
in  renal  or  heart  disease  if  albumin  be 
present  in  the  urine.  H.  Huchard  (Revue 
Gen.  de  Clin,  et  de  Ther,  Apr.  25,  '89). 

Continuance  of  the  treatment  during 
diuresis  will  not  alter  or  increase  the 
effect.  Its  action  is  most  marked  in 
dropsies  due  to  heart  disease.  Its  action 
in  dropsies  of  hepatic  origin  is  not  to  be 
relied  upon.  Pathological  changes  in  the 
kidney  prevent  or  abridge  its  action. 
Small  doses  will  prove  of  no  avail.  The 
diuretic  action  may,  in  all  probability, 
be  ascribed  to  the  irritating  effect  which 
the  mercury,  during  its  elimination,  ex- 
ercises upon  the  renal  epithelium.  G.  A. 
Fackler  (Jour.  Amer.  Med.  Assoc.,  Aug. 
16,  '90). 

Calomel  is  an  excellent  diuretic,  and  is 
especially  useful  in  cardiac  dropsy.  The 
action  is  greater  in  the  absence  of  renal 
complications.  Dosage  must  be  guarded 
(maximum  1 7/8  grains  every  two  hours) 
and  first  symptoms  of  mercurial  poison- 
ing closely  noted.  In  case  of  a  weak 
heart,  a  combination  of  calomel  and 
digitalis  recommended.  Finkelstein  (In- 
ter, klin.  Rund,  July  25,  '95). 

Literature  of  '96-'97-'98. 

Calomel  is  the  best  cardiac  diuretic,  if 
given  in  suitable  doses  and  for  a  sufficient 
length  of  time.  It  may  be  given  in  severe 
cases  of  dropsy  due  not  only  to  valvular 
disease,  but  also  to  cardiac  failure  from 
fatty  degeneration,  atheroma,  and  myo- 
carditis. In  fatty  heart  it  is  a  specific,  as 
it  not  only  causes  profuse  diuresis,  but 
causes  the  absorption  of  fat.  When  using 
calomel  as  a  diuretic  it  should  be  given 
for  six  to  eight  days  in  about  1-grain 
doses  five  times  in  twenty-four  hours,  at 
intervals  of  three  to  four  hours.  Profuse 
diuresis  sets  in,  as  a  rule,  on  the  fifth 
day.  When  this  occurs,  calomel  should 
not  be  abandoned,  but  continued  till 
dropsy  quite  disappears.  On  the  sixth  or 
seventh  day,  when  diuresis  is  fully  estab- 
lished infusion  of  digitalis  may  be  pre- 
scribed with  additional  benefit.  If  the 
dropsy  has  not  disappeared  after  the  first 
course  (eight  days)  the  treatment  may 


CHLORIDES.  619 

be  repeated  after  a  pause  of  eight  days. 
Thirst  may  be  allayed  by  sucking  pieces 
of  ice.  Large  consumption  of  fluids 
should  be  avoided.  Mild  stomatitis, 
gingivitis,  colic,  bloody  stools,  hoarse- 
ness, etc.,  need  not  interrupt  the  calomel 
treatment.  Should,  however,  diarrhoea 
be  severe,  the  dose  may  be  reduced  to 
three  or  four  powders  a  day.  Arbold 
Landau  (Wiener  med.  Presse,  No.  29, 
'97). 

Calomel  lias  also  been  used  as  a  diu- 
retic in  renal  hepatic  disorders,  but  the 
clinical  reports  have  been  contradictory. 
Its  behavior  in  the  treatment  of  cardiac 
disorders  would  tend  to  demonstrate  that 
renal  lesions  inhibit  diuresis;  hence  it 
is  doubtful  whether  it  can  even  be  pre- 
scribed with  safety. 

Mercury  acts  as  a  diuretic,  especially 
in  cardiac  troubles,  while  it  is  of  little  or 
no  use  in  dropsies  of  renal  origin,  or  in 
hepatic  ascites  and  pleural  effusions. 
Jendrassik  (Deutsches  Archiv  f.  klin. 
Med,  B.  10,  H.  7,  '91). 

In  seven  out  of  fourteen  cases  of  well- 
defined  Bright's  disease,  accompanied 
with  oedema,  calomel  was  found  superior 
to  all  other  diuretics.  Sklidowski 
(Deutsches  Arch.  f.  klin.  Med.,  B.  52, 
H.  3,  4,  '94). 

In  ascitic  hepatic  disorders,  especially 
cirrhosis,  the  results  reported  seem  to 
warrant  a  further  trial  of  calomel  as  a 
diuretic.  As  small  doses  are  recom- 
mended, it  can  safely  be  administered. 

Excellent  results  obtained  from  calomel 
in  a  case  of  hypertrophic  cirrhosis  in  a 
man  of  30  years.  During  the  first  month 
1  grain  was  given  six  times  a  day  (every 
two  hours),  every  three  days  of  treat- 
ment being  followed  by  three  days  of 
repose.  The  second  month,  four  doses 
per  day  were  given  for  three  days,  and 
again  followed  by  three  days  of  repose. 
The  pain  ceased,  icterus  disappeared,  and 
there  was  a  notable  diminution  in  the 
size  of  the  hypertrophied  liver  and  spleen. 
Iodide  of  potassium^  entirely  failed  in  this 
case.  L.  Sior  (Berliner  klin.  Woch.,  Xo. 
52.  '92). 


620  MERCURY. 

In  those  cases  of  biliary  affections,  as  | 
calculi  and  catarrhal  icterus,  and  even  in  j 
hypertrophic  cirrhosis  of  the  liver,  in 
which  the  usual  treatment  fails,  the  use 
of  calomel  recommended.  It  must  be 
given  in  doses  of  1  grain  every  hour  for 
five  consecutive  hours,  and  the  same  dose 
continued  every  two  hours  until  the  pain 
disappears  and  the  temperature  returns 
to  normal.  Zakharine  (Medycyna,  No.  1, 
'91). 

In  gall-stones  and  diseases  of  the  bil- 
iary passages  calomel  acts  not  by  increas- 
ing the  biliary  excretion,  but  by  its  dis- 
infecting properties,  thus  diminishing  the 
abnormal  irritation  of  the  mucous  mem- 
brane of  the  gall-bladder.  V.  Schultz 
(Berliner  klin.  Woch.,  No.  G,  '94). 

Calomel  has  recently  been  used  with 
advantage  in  lupns.  It  was  given  hyp- 
odermically  in  small  doses. 

Literature  of  'SQ-'dl-'dS. 

Case  of  a  woman,  with  tuberculous 
lupus  of  the  face,  in  which  a  cure  fol- 
lowed the  use  of  injections  of  calomel. 
Fournier  (Ann.  de  Derm,  et  de  Syph., 
Xo.  5,  '97). 

Fourteen  out  of  twenty-five  cases  of 
tubercular  lupus  in  which  calomel  treat- 
ment has  been  tried,  all  the  injections 
have  been  made  with  3/4  grain  in  the  but- 
tocks; at  first,  on  the  average,  about  ten 
in  ten  days;  then  longer  intervals  were 
necessary,  owing  to  pain,  induration,  etc. 
The  action  of  calomel  upon  true  tubercu- 
lar lupus  is  certain  and  indisputable. 
Improvement  is  most  marked  after  first 
injections.  This  treatment  appears  to  be 
of  use  in  old  ulcerated  tubercular  lupus, 
turgescent,  with  profound  infiltration. 
The  more  superficial  forms  and  lupus 
erythematosus  are  less  affected.  Assel- 
bergs  (Ann.  de  Derm,  et  de  Syph.,  Jan., 
*98). 

Local  Uses.  —  Calomel  was  at  one 
time  considerably  used  locally  as  a  stimu- 
lant in  chronic  inflammatory  and  ulcera- 
tive processes  of  the  skin  and  mucous 
membranes,  particularly  in  chronic  ec- 
zema, herpes  and  syphilitic  eruptions, 
and  phlyctenular  conjunctivitis,  atrophic 


CHLORIDES. 

rhinitis,  syphilitic  laryngitis,  etc.  Since, 
however,  its  toxic  effects  have  been  better 
understood,  the  indiscriminate  use  of 
calomel  thus  involved  has  greatly  de- 
creased. When  used  in  phlyctenular  con- 
junctivitis, iodide  of  potassium  should 
not  be  used  simultaneously,  an  irritating 
compound  being  formed  with  what  por- 
tion of  the  iodide  is  eliminated  with  the 
lacrymal  secretion. 

Therapeutics  of  Corrosive  Sub- 
limate.— Aside  from  its  uses  as  an  anti- 
septic (see  Wounds,  volume  vi)  and  in 
syphilis  (see  article  on  Syphilis),  the 
useful  applications  of  corrosive  subli- 
mate are  very  similar  to  those  of  calomel, 
but,  of  course,  in  doses  commensurate 
with  its  greater  strength.  Here,  again, 
the  activity  of  mercury  as  a  tonic  be- 
comes manifest,  provided  very  small 
doses  are  adhered  to. 

In  the  summer  diarrhoea  of  children 
and  adults  very  small  doses  are  especially 
effective,  yi00-grain  doses  being  repeated 
every  hour  or  two.  It  stimulates  the  in- 
testinal tract  and  acts  as  a  germicide, 
thus  arresting  putrefaction,  and  rids  it 
of  its  contents  by  gentle  catharsis.  It 
has  also  been  found  valuable  in  dysen- 
tery, administered  in  somewhat  large 
doses.  Corrosive  sublimate  has  also  been 
used  with  advantage  by  rectal  injections 
in  the  latter  disease. 

For  the  treatment  of  dysentery,  ene- 
mata  of  bichloride  of  mercury  success- 
fully employed  in  cases  where  ipecacu- 
anha had  failed,  and  where  the  patients 
complained  from  the  beginning  of  nausea 
and  vomiting.  Two  hundred  and  two 
patients  were  treated  by  calomel  by  the 
mouth  and  enemata  of  oichloride  of  mer- 
cury. To  those  who  had  no  gastric  in- 
tolerance calomel  was  given  in  minute 
doses  at  first.  For  others  the  enemata  of 
the  mercuric  salt  were  as  follow:  Of  a 
solution  of  the  corrosive  sublimate,  1 
part  to  5000,  three  enemata  of  G  l/4  ounces 
each  were  employed  per  day  at  first. 


MERCURY.    CHLORIDES.  621 


Later  on,  only  one  enema  of  3  to  1000 
parts  was  administered  during  the  day. 
The  enemata  should  be  given  lukewarm, 
and  for  some  patients  a  few  drops  of 
laudanum  may  be  added  to  the  injec- 
tions. Lemoine  (Amer.  Practitioner  and 
News,  Mar.  29,  '90). 

Bichloride  of  mercury  successfully  em- 
ployed in  dysentery.  Solution  of  1  in 
6000,  or  Vj  grain  to  6  ounces  of  water, 
was  given  by  rectal  injection.  Of 
seventy-five  cases  recently  treated  there 
were  but  three  deaths,  all  the  others 
being  completely  cured.  Roudneff 
(Medit.  Oboz.,  No.  20,  '93). 

Mercuric  bichloride  has  been  found 
efficacious  in  the  active  manifestations  of 
gonorrhoea,  especially  in  women,  and  in 
gonorrhoeal  rheumatism. 

Subcutaneous  injections  of  the  bichlo- 
ride of  mercury  highly  recommended  for 
the  treatment  of  gonorrhoeal  rheumatism. 
Jullien  (La  Sem.  Med.,  May  16,  '91). 

For  gonorrhoeal  vulvitis  every  part 
should  be  painted  every  day  thoroughly 
with  a  solution  of  silver  nitrate  (20 
grains  to  the  ounce).  In  cases  with  ten- 
der mucosae,  as  in  blonds  and  very  young 
women,  every  other  day  is  sufficient.  To 
prevent  extension  the  vagina  is  to  be 
packed  with  iodoform  gauze,  previously 
wrung  out  in  1  to  5000  bichloride  solu- 
tion, and  this  must  be  renewed  once  in 
three  days.  The  vulva  should  be  bathed 
every  four  hours  in  a  lysol  solution. 
Pry  or  (Amer.  Gyn.  and  Obst.  Jour.,  Sept., 
'95). 

Literature  of  '96-'97-'98. 

Treatment  of  rectal  gonorrhoea  in 
women  consists  in  irrigation  of  the  rec- 
tum twice  daily,  through  a  speculum, 
with  a  3-per-cent.  solution  of  boric  acid, 
followed  by  mercuric  chloride,  1  to  8000, 
half  a  litre  of  each  being  used.  The  ero- 
sions are  touched  with  argentamine,  2 
per-cent.  solution.  Baer  (Deut.  med. 
Woch.,  No.  8,  '96). 

It  has  also  been  highly  recommended 
for  the  treatment  of  diphtheria,  Vioo 
grain  being  given  every  three  hours; 
but  antitoxin  is  a  much  more  effective 


agent  and  should  be  given  the  prefer- 
ence. 

On  the  whole,  the  internal  administra- 
tion of  bichloride  in  other  than  syph- 
ilitic affections  has  not  received  much 
support  from  the  profession,  owing  to 
the  fear  of  causing  salivation  and  other 
manifestations  of  mercurial  poisoning. 
Calomel  has  usually  been  emplo}red, 
though,  in  truth,  this  agent  is  more 
liable  to  give  rise  to  toxic  symptoms 
than  the  bichloride. 

Literature  of  '96-'97-'98. 

Uniform  success  with  mercury  in  cere- 
brospinal meningitis;  1/i  grain  of  mer- 
curic chloride  hypodermically  at  first 
and  then  Vis  grain  every  hour  until  there 
are  symptoms  of  gastro-intestinal  irrita- 
tion Smith  (Jour.  Amer.  Med.  Assoc., 
June  13,  '96). 

Good  results  from  mercury  in  9  cases 
of  cerebro-spinal  meningitis  occurring  in 
an  epidemic  of  grip.  Only  1  case  proved 
fatal.  The  dose  varied  from  1/18  to  Vt 
grain  of  the  bichloride  according  to  the 
age  of  the  patient,  administered  hypo- 
dermically once  in  twenty-four  hours  in 
the  beginning  and  later  once  in  forty- 
eight  hours.  Consalvi  (La  Sem.  Med., 
Jan.  15,  '96). 

Case  of  pernicious  ansemia  in  which 
mercuric-chloride  injections  were  used,  1/0 
grain  being  administered  daily  for  two 
months.  Under  this  treatment  the  an- 
aemia disappeared  and  the  patient  im- 
proved in  every  way.  Patera  (Riforma 
Med.,  May  28,  '96). 

Three  cases  of  severe  anaemia  in  which 
injections  of  mercuric  chloride  and  qui- 
nine were  used  with  good  results.  De 
Francesco  (Gaz.  degli  Osped.,  Feb.  4.  '96). 

Local  Uses. — The  external  uses  of  bi- 
chloride of  mercury,  besides  its  applica- 
tion to  the  operative  field,  are  very  nu- 
merous. 

Surgical  Mycoses. — In  the  treatment 
of  furuneulosis  or  boils,  it  is  extremely 
valuable  and  often  succeeds  in  arresting 
them  when  used  early.    Compresses  of 


622  MERCURY. 

a  1  to  500  solution  applied  over  the  spot 
— or,  when  the  furuncle  shows  its  first 
signs  on  an  extremity,  baths  of  this 
strength — are  very  valuable.  The  threat- 
ened region  should  be  kept  moist  with 
the  solutions,  however. 

As  infection  takes  place  from  the  out- 
side, the  following-  treatment  is  success- 
ful: The  entire  skin  is  cleansed  by  a 
warm  bath  with  soft  soap.  The  furuncle 
and  the  surrounding  skin  are  washed 
with  a  1  to  1000  solution  of  mercuric 
chloride.  The  boil  is  then  covered  with 
phenol  and  mercury  plaster-mull,  and 
the  patient  puts  on  clean  linen.  Twice  a 
day  new  plasters  are  applied,  and  if  the 
furuncle  has  opened  the  pus  is  gently 
squeezed  out  and  the  entire  region  care- 
fully disinfected  with  the  mercuric  solu- 
tion. Van  Hoorn  (Monats.  f.  prakt.,  B. 
19.  Xo.  1). 

In  onychia  maligna,  malignant  pus- 
tule, and  anthrax  these  applications  are 
also  of  great  value.  The  effect  is  en- 
hanced by  using  warm  solutions.  It  is 
also  used  with  advantage  in  many  skin 
disorders,  including  those  attending  in- 
fectious fevers.  In  small-pox  it  is  quite 
effective  in  the  prevention  of  pitting. 

New  way  to  use  mercury,  especially 
the  corrosive  sublimate,  for  preventing 
the  pitting  of  small-pox:  A  solution  of 
the  salt  is  to  be  supplied  by  means  of  an 
atomizer  in  the  following  manner:  For 
the  first  or  second  day  of  the  eruption, 
the  face  is  to  be  washed  with  soap  and 
M  ater,  rinsed  with  bora  ted  water,  and 
wiped  dry  with  absorbent  cotton  before 


CHLORIDES. 

using  the  atomizer.  After  the  third  day 
the  washing  is  unnecessary:  the  eye- 
are  now  protected  with  borated  wadding, 
and  the  solution  applied  with  the  atom- 
izer. In  this  way  the  skin  is  given  a 
frosty  appearance,  and  the  danger  of 
blistering  by  too  copious  a  dose  is 
avoided.  The  spray  is  to  be  applied 
chiefly  to  incipient  pustules.  Fifteen 
minutes  after  this  operation  of  atomizing, 
which  should  not  last  more  than  a  min- 
ute, the  face  is  to  be  rubbed  with  a 
pledget  of  wadding  dipped  in  a  glycerin 
solution  of  sublimate  of  the  strength  of 
Vj  drachm  to  the  ounce,  the  operation  to 
be  repeated  three  or  four  times  during 
the  twenty-four  hours  in  the  hist  three 
days,  twice  until  the  sixth  or  seventh 
day,  when  the  spray  may  be  suspended 
and  the  glycerin  painting  continued  until 
the  scabs  begin  to  drop  off.  Results  were 
highly  successful  except  in  cases  of  con- 
fluent small-pox;  salivation  never  oc- 
curred. 

The  spray-solution  is  made  up  as  fol- 
lows:— 

R  Corrosive  sublimate,  15  grains. 
Citric  acid,  15  grains. 
Alcohol.  90°,  75  minims. 
Ether,  q.  s.  to  make  12 1/2  ounces. 
— M. 

This  solution  contains  2  per  cent,  by 
volume  of  sublimate.  Talamon  (Ther. 
Gaz.,  May,  '90). 

The  bichloride  of  mercury  is  employed 
locally  in  many  diseases,  and  is  intro- 
duced under  each  general  heading. 
Charles  E.  de  M.  Sajous, 

Philadelphia. 


